California Major Risk Medical Insurance Program (MRMIP) by bxj13101

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									        California
       Major Risk
  Medical Insurance
          Program
         (MRMIP)



2010 Application and Handbook




   Rates effective January 1, 2010
California Major Risk
Medical Insurance Program
Visit our website at: www.mrmib.ca.gov                                                                                         MRMIP Enrollment Unit
                                                                                                                        1-800-289-6574
                                                                                                                         Monday – Friday
                                                                                                                     8:30 a.m. – 7:00 p.m.
P.O. Box 2769                                             Table of Contents
Sacramento, CA 95812-2769
1-916-324-4695                                            Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Arnold Schwarzenegger, Governor                           Eligibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
                                                          How the Program Works . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Board Members
Clifford Allenby, Chair                                   Description of Plans and Benefit Highlights
Areta Crowell, Ph.D.
Richard Figueroa, M.B.A.                                       Anthem Blue Cross PPO. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Sophia Chang, M.D., M.P.H.                                     Contra Costa Health Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Ex Officio Members                                             Kaiser Permanente Northern California . . . . . . . . . . . . . . . . . 12
Jack Campana
Kimberly Belshé                                                Kaiser Permanente Southern California . . . . . . . . . . . . . . . . . 14
Dale E. Bonner                                            Monthly Subscriber Contributions . . . . . . . . . . . . . . . . . . . . . . . 16
Executive Director                                        Enrollment Application Checklist . . . . . . . . . . . . . . . . . . . . . . . . 22
Lesley Cummings
                                                          Enrollment Application . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Americans with Disabilities Act                           1-800-289-6574
Section 504 of the Rehabilitation Act of 1973 states
that no qualified disabled person shall, on the basis
of disability be excluded from participating in, be
denied the benefits of, or otherwise be subjected to
discrimination under any program or activity which         3
receives or benefits from federal financial assistance.

The Americans with Disabilities Act of 1990                                                                                3
prohibits the Managed Risk Medical Insurance Board
                                                                                                                                        3
and its contractors from discriminating on the basis
of disability, protects its applicants and enrollees
with disabilities in program services, and requires the                          3
Board and its eligibility and enrollment contractors to
make reasonable accommodations to applicants                                                 1
and enrollees.

The Managed Risk Medical Insurance Board has                                                                                   3
designated an ADA Coordinator to carry out its
                                                                                                                                            3
responsibilities under the Act. If you as a client have
any questions or concerns about ADA compliance                                           3
by the Board or its contractors, you may contact the
Coordinator at the following address:
                                                                                     3
ADA Coordinator
Managed Risk Medical Insurance Board                                                                                   3
P.O. Box 2769
Sacramento, CA 95812-2769                                                                              2
1-916-324-4695 (Voice)
The hearing impaired can contact the ADA                                                               3
Coordinator through the California Relay Services
at 1-800-735-2929.                                                                               3
Introduction                                 4. You must be unable to secure              Applicants Who Know They Are
                                                adequate coverage within the              Currently Not Eligible But Expect
The California Major Risk Medical               previous 12 months. This can be           To Be in the Future (Deferred
Insurance Program (MRMIP) is a                  demonstrated in any of three ways:        Enrollment)
program developed to provide health
insurance for Californians who are              • You have been denied individual         If you are not currently eligible for the
unable to obtain coverage in the                  coverage. A letter or a copy from a     MRMIP, but anticipate becoming
individual insurance market. MRMIP                health insurance carrier, health plan   eligible, you may also apply. Examples of
is administered by a five-member Board            or health maintenance organization      this are: if you are currently enrolled in
which established a comprehensive benefit         denying individual coverage             COBRA or Cal-COBRA coverage or if
package. Services are delivered through           within the last 12 months must be       your employer has informed you that you
                                                  submitted with your completed           will be involuntarily terminated from
contracts with health insurance plans.
                                                  application. Insurance denial           insurance coverage sometime in
MRMIP subscribers participate in the
                                                  notifications received through the      the future.
payment for the cost of their coverage by
                                                  internet that does not provide the
paying subscriber contributions, an annual                                                To apply for deferred enrollment,
                                                  reason for denial and the applicant’s
deductible, and copayments. MRMIP                                                         indicate when you will become eligible
                                                  name will not be accepted.
supplements subscriber contributions                                                      and include acceptable documentation.
to cover the cost of care and is funded         • You have been involuntarily             Acceptable documentation is a letter
annually by tobacco tax funds.                    terminated from health insurance        from a health insurance carrier, health
                                                  coverage for reasons other than         plan, health maintenance organization,
Eligibility                                       nonpayment of premium or                or employer indicating when your
In order to be eligible for the MRMIP:            fraud. A letter or a copy indicating    coverage will end. The documentation
                                                  involuntary termination from            must specify the exact date of when
1. You must be a resident of the state of         a health insurance carrier,             your current coverage will terminate.
   California. A resident is a person who         health plan, health maintenance         Enrollment in temporary policies does
   is present in California with intent           organization or employer for            not qualify for deferred status.
   to remain in California except when            reasons other than nonpayment
   absent for transitory or temporary                                                     If the MRMIP is not at maximum
                                                  of premium or fraud must be
   purposes. However, a person who                                                        enrollment and all other eligibility criteria
                                                  submitted with your completed
   is absent from the state for a period                                                  are met, you will be enrolled in the
                                                  application.
   greater than 210 consecutive days                                                      MRMIP the month determined you are
   shall not be considered a resident.          • You have been offered an                eligible. If the MRMIP is at maximum
                                                  individual, not a group, health         enrollment at the time you become
2. You cannot be eligible for Medicare            insurance premium in excess of the      eligible, your application will be placed on
   both Part A and Part B unless                  MRMIP subscriber contribution           a waiting list. Your place on the waiting
   eligible solely because of end-stage           amount. A letter or a copy must         list is determined by the date on which
   renal disease. Provide a Medicare              be submitted with the completed         your completed application was received,
   eligibility letter with the application        application indicating that,            not the date that you became eligible for
   as proof of end-stage renal disease.           within the last 12 months, you          the MRMIP.
   (Being eligible for only one part of           have been offered by a health
   Medicare is acceptable.)                                                               Applicants for deferred enrollment
                                                  insurance carrier, health plan or
                                                                                          must submit their initial subscriber
3. You cannot be eligible to                      health maintenance organization, a
                                                                                          contribution with their application.
   purchase any health insurance for              premium in excess of the MRMIP
                                                                                          Payment will be refunded to you
   continuation of benefits under                 subscriber contribution amount
                                                                                          immediately if your deferred effective
   COBRA or Cal-COBRA. (COBRA                     (based on subscriber’s MRMIP
                                                                                          date is more than 60 days from the date
   and Cal-COBRA refer to the federal             health plan choice).
                                                                                          MRMIP received your application.
   and state laws giving people under            Note: Letters from agents/brokers
   certain circumstances the right to            indicating that an individual is         Agents/Brokers, Employers
   continue coverage in an employee              unable to secure adequate private        and Applicants
   health plan for a limited time.) If you       coverage will not be accepted as         Insurance Code Section 12725.5
   have COBRA or Cal-COBRA, you                  documentation for eligibility.           states that it shall constitute unfair
   may apply for deferred enrollment.                                                     competition for an insurer, an insurance


                                                                 2
agent or broker, or administrator to           Deductible                                   Please review the individual plan pages
refer an individual employee or their                                                       for details on which services are subject
                                               The MRMIP has an annual household
dependent(s) to apply for MRMIP with                                                        to the deductible.
                                               $500 deductible you must satisfy before
the purpose of separating that employee
                                               the plan will begin paying for covered       Copayments/Coinsurance
or their dependent(s) from group health
                                               services. You are responsible for charges
coverage provided in connection with                                                        Health Maintenance Organizations
                                               for certain covered services subject to
the employee’s employment.                                                                  (HMOs) in MRMIP may require a fixed
                                               the deductible and the plans will not
Insurance Code Section 12725.5 further         pay for these services until you meet        dollar copayment for some services and
states that it shall constitute an unfair      the deductible in that calendar year.        up to 25% of the cost for other services.
labor practice contrary to public policy       The only payments that count toward          The Preferred Provider Organization
for any employer to refer an individual        a deductible are those payments you          (PPO) in MRMIP may also require
employee or their dependent(s) to the          make for covered services that are subject   a fixed dollar copayment for certain
MRMIP or to arrange for an individual          to the deductible. After you meet the        services and up to 25% of the cost for
employee or their dependent(s) to              deductible and for the remainder of          other services.
apply for MRMIP with the purpose               the calendar year, you pay only the          The out-of-pocket maximum per
of separating that employee or their           applicable copayments or coinsurance         calendar year for MRMIP is $2,500
dependent(s) from group health coverage        subject to the annual out-of-pocket          for individuals and $4,000 for an entire
provided in connection with the                maximum. Payments for services               household covered by the MRMIP.
employee’s employment.                         provided by In-Network and Out-of-           This maximum does not apply to
                                               Network Providers and prescription           services received by providers that do
Medi-Cal Beneficiaries                         payments may apply toward the $500
                                                                                            not participate in the subscriber’s chosen
While Medi-Cal beneficiaries are not           annual deductible. The $500 annual
                                                                                            health plan’s provider network, or to
prohibited from enrolling in the MRMIP,        deductible is applied to the annual
                                                                                            services not covered by the MRMIP.
a Medi-Cal beneficiary should carefully        out-of-pocket maximum.
                                                                                            There are MRMIP benefit limits of
consider the cost before signing up for        Each plan is applying the deductible         $75,000 per calendar year and $750,000
MRMIP coverage. MRMIP subscribers              differently. However, the following          in a lifetime.
are responsible for their monthly subscriber   covered Preventive Care Services with
contributions, annual deductible, and a                                                     Please refer to the health plan’s Evidence
                                               applicable copayments are not subject to
copayment for services, which could be                                                      of Coverage or Certificate of Insurance
                                               the calendar year deductible in any plan.
more than $5,000 per year. Medi-Cal                                                         booklet to read more about the plan’s
Benefits Identification Cards (BICs) cannot    • Breast Exams, Pelvic Exams, Pap            out-of-pocket expenses. Out-of-pocket
be used for the MRMIP.                           Smears, and Mammograms for                 expenses are costs you may have to pay
                                                 Women                                      for certain services
How the Program Works                          • Cytology Examinations                      Subscriber Contributions
Choosing a Health Plan                         • Periodic Health Examinations               Subscriber contribution amounts are
The health plans participating in the          • Hearing Tests and Eye Exams                updated on January 1 of each year. In
MRMIP provide comprehensive medical              for Children                               addition, your subscriber contribution
benefits for inpatient and outpatient                                                       may change during the year if your
                                               • Newborn Blood Tests
hospital and physician services. These                                                      birthday moves you into a new age
benefits are outlined in the health plan       • Prenatal Care (care during pregnancy)      category or if you add dependents.
description pages in this brochure and
                                               • Prostate Exams for Men                     For subscribers with enrolled
are also available by calling any MRMIP
                                               • Venereal Diseases Tests                    dependents, the age category will be
health plan at its toll-free number and
                                                                                            based on the age of the applicant.
asking for an Evidence of Coverage             • Well-Baby and Well-Child Visits            Adjustments to subscriber contributions
or Certificate of Insurance booklet.
                                               • Certain Immunizations for Children         due to age changes will occur on the first
Subscribers may choose from any plan
                                                 and Adults                                 of the month following the birthdate of
available to them depending on where
                                                                                            the applicant.
they live, as listed on pages 16-21. Please    • Laboratory Services in connection
review all pages carefully to select a           with Periodic Health Evaluations           Subscriber contributions may also change
plan that is right for you.                                                                 when a member moves from one area
                                               • Other (depends on the plan)

                                                                   3
of the State to another or if a member     to date. Any further reinstatements will    Pre-Existing Condition Exclusion
transfers to a different health plan.      require a written appeal to the Managed     Period
Adjustments to subscriber contributions    Risk Medical Insurance Board for
                                                                                     “Pre-existing condition” means
will occur on the first of the month       consideration.                            any condition for which medical
following notification of the move or on   Subscribers may pay by check, money       advice, diagnosis, care, or treatment,
the effective date of your transfer.       order or may elect to have their monthly including use of prescription drugs,
Each month you will receive a subscriber subscriber contribution automatically       was recommended or received from
contribution notice from MRMIP.            paid from their checking account when a licensed health practitioner during
Subscriber contributions are payable       accepted into the MRMIP. In addition, the six months immediately preceding
in advance and are due the first day of    a federally recognized California Indian enrollment in the MRMIP.
every month. A subscriber contribution     tribal government can make required
                                                                                     For subscribers and dependents enrolled
notice will be generated monthly, and      subscriber contributions on behalf of a
                                                                                     in a Preferred Provider Organization
will be sent out 30 days prior to the      member of the tribe.
                                                                                     (PPO), there is a pre-existing condition
due date. Please make check payable to     Subscriber contribution checks and        exclusion period of three months. During
the California Major Risk Medical          electronic withdrawals that are returned this period, no benefits or services related
Insurance Program.                         by the subscriber’s bank for insufficient to a pre-existing condition are covered.
Subscribers now have several billing       funds may result in a retroactive         However, subscriber contributions are
options, which include monthly,            disenrollment date. The subscriber        paid during this period.
bi-monthly, and quarterly premium          will be charged a processing fee for
                                           each payment received as having non-      Post-Enrollment Waiting Period
billing, as well as monthly electronic
checking account withdrawal.               sufficient funds. In addition, electronic For subscribers and dependents enrolled
                                           withdrawals that are returned unpaid      in a Health Maintenance Organization
Subscribers are responsible for their      from the subscriber’s bank will result in (HMO), there is a post-enrollment
monthly subscriber contributions           removal from electronic withdrawal and waiting period of three months. No
whether or not they receive a bill, or if  require immediate payment by check or benefits or services are provided to
the premium is paid by a third party.      money order. Upon written request to      subscribers and enrolled dependents
A delinquency billing or final notice will reinstate, the subscriber must include    during this period. Subscribers will be
be sent out on the 15th day following      a check or money order of subscriber      informed of when this period begins
the due date.                              contributions to bring the account to     and ends.
There is a grace period of 31 days from current status with an additional $25.00
                                                                                     No subscriber contributions are paid
the due date, and the member’s coverage processing fee.
                                                                                     during this waiting period. The initial
will remain in effect during this time.    There is no application fee for           one-month subscriber contribution will
Disenrollment for nonpayment of a          applying to the MRMIP. You are            be applied to the first month of service.
subscriber contribution will occur on      required to submit your first month’s
the 32nd day after the due date. The       subscriber contribution for MRMIP         How You May Waive All or Part of
end date of coverage will be retroactive   health care coverage. This payment        the Exclusion/Waiting Period
to the last day of the month in which      is completely applied towards your        The exclusion/waiting period requirement
the subscriber contribution was paid in    first month of coverage if you are        may be waived in part or all if:
full, and a disenrollment letter will be   enrolled. Cashing your check does
mailed to the subscriber. Subscribers      not guarantee enrollment. Qualified       1. The subscriber and enrolled
are responsible for the cost of any        insurance agents and brokers may              dependents have been on the
services received after the disenrollment  be paid a $50 fee by the State for            MRMIP waiting list for 180 days
                                           explaining the MRMIP and assisting            or longer. In this circumstance, the
date. Subscribers who are disenrolled
                                           you in completing the application, if         exclusion/waiting period will be
for nonpayment of their subscriber
                                           you are enrolled. The State does not          completely waived.
contributions may be reinstated upon
written request only once in a consecutive require an individual applying to the 2. The subscriber and enrolled
12-month period. The subscriber must       MRMIP to pay any fee, charge or               dependents were previously insured
request reinstatement in writing within 60 commission to a broker or agent.              by another health insurance policy
calendar days of the date of disenrollment                                               (including Medicare and Medi-Cal)
and bring all delinquent payments up                                                     and the application for enrollment


                                                               4
   in the MRMIP was made within             Dependent Coverage Information                  1-800-289-6574 and talking
   63 days of the termination of                                                            to a MRMIP Enrollment Unit
                                            1. Dependents may be covered under
   the previous coverage. In these                                                          representative.
                                               the MRMIP and are defined as
   circumstances, you may be granted           a subscriber’s spouse, registered         3. Enrolled dependents of a deceased
   a waiver up to three months. If the         domestic partner, and any unmarried          subscriber or dependents of a
   coverage was less than three months         child who is an adopted child, a             subscriber who becomes eligible
   but was at least one month, the             stepchild, a recognized natural child        for Medicare (Parts A and B) are
   subscriber and enrolled dependents          under age 23, or a registered domestic       eligible to continue coverage in
   will be given credit for either one or      partner’s own separate child. A child        the MRMIP as long as program
   two months toward their MRMIP               under age 23 cannot be married or            requirements are met.
   exclusion/waiting period.                   have a registered domestic partner.
                                                                                         Waiting List
                                               A dependent also includes any
3. The subscriber and enrolled                                                           If the MRMIP reaches maximum
                                               unmarried child who is economically
   dependents were insured by another          dependent upon the applicant. An          enrollment, applicants and dependents
   health insurance policy that ended          unmarried child over 23 years old may     will be placed on a waiting list. Applicants
   because of a loss of employment,            be covered if that unmarried child is     and dependents will be enrolled when
   or because the employer stopped             incapable of self-support because of      spaces become available in order of the
   offering or sponsoring health               physical or mental disability which       date of receipt on which the completed
   coverage, or because the employer           occurred before the age of 23. An         application was received. Any time spent
   stopped making contributions                applicant must provide documentation      on the waiting list does not count toward
   towards health coverage and                 in the form of doctors’ records which     the three-month pre-existing condition
   application for enrollment in the           show that the dependent child cannot      exclusion period or post-enrollment
   MRMIP was made within 180 days              work for a living because of a physical   waiting period (once enrolled) unless the
   of the termination of the previous          or mental disability which existed
                                                                                         applicant has been on the waiting list for
   coverage. In these circumstances,           before the child became 23.
                                                                                         at least 180 days. If the applicant has been
   you may be granted a waiver of up        2. It is the responsibility of subscribers   on the waiting list 180 days or longer, the
   to three months.                            to notify the MRMIP about changes
                                                                                         full three-month exclusion/waiting period
                                               in the number of dependents.
4. The subscriber and enrolled                                                           will be waived.
                                               Coverage for newborn children shall
   dependents were receiving                   begin upon birth if the request is        Transfer of Enrollment
   coverage under a similar program            made within 60 days of birth.             Subscribers and enrolled dependents may
   in another state within the last 12
                                               Stepchildren are eligible for MRMIP       transfer from one participating health plan
   months. In this circumstance, the
                                               dependent coverage upon marriage          to another if any of the following occur:
   exclusion/waiting period will be            by a subscriber to the stepchildren’s
   completely waived.                                                                    1. The subscriber so requests, in
                                               parent or at the time the stepchildren
                                               lose other health coverage.                  writing, during the program’s open
If you have met the criteria in #2, #3,
                                                                                            enrollment period which is held in
or #4 to waive this exclusion/waiting          The domestic partner’s children
                                                                                            November. Subscribers will receive an
period, please submit appropriate              are eligible for MRMIP dependent
                                                                                            open enrollment packet containing
documentation and check the                    coverage upon the parent being a
                                               registered domestic partner with the         the plan choices and the new rates.
appropriate boxes on the application
(Program Eligibility Questions #5              subscriber or at the time the children       All open enrollment transfers will
and/or #6).                                    lose other health coverage.                  be effective January 1. All enrolled
                                               In all cases, the MRMIP must be              dependents will also be transferred to
All documentation must be received             notified within 60 days. If eligible,        the new plan.
prior to or with your first month’s            dependents are covered within             2. The subscriber requests a transfer
subscriber contribution.                       90 days of the MRMIP being
                                                                                            in writing because the subscriber
                                               notified. Dependents age 18 and
The subscriber dependents age 18                                                            has moved and no longer resides in
                                               under qualify for a full pre-existing
and under are not subject to the pre-          or post-enrollment waiver.                   an area served by the health plan in
existing condition exclusion period or                                                      which they are enrolled and there is
                                               To add a dependent to your
the post-enrollment waiting period.                                                         at least one participating health plan
                                               policy, you may request an “Add
                                                                                            serving the subscriber’s new area.
                                               Dependent” application by calling


                                                                5
3. The subscriber or participating              Unit in writing when they become          The Managed Risk Medical Insurance
   health plan requests a transfer in           eligible for Medicare Part A and Part     Board (MRMIB) Appeals Process
   writing because of the failure to            B. Disenrollment will be effective at
                                                                                          The subscriber should first attempt to
   establish a satisfactory subscriber/         the end of the month in which the
                                                                                          resolve the dispute with the participating
   plan relationship and the Executive          notification was received or the end
                                                                                          plan according to its established policies
   Director determines that the                 of the month in which the subscriber
                                                                                          and procedures.
   transfer is in the best interest of the      contribution was paid in full.
   MRMIP and there is at least one                                                        This is a State program and the
                                             4. The subscriber or enrolled
   participating health plan serving the                                                  subscriber’s rights and obligations will be
                                                dependents have committed an act
   subscriber’s area.                                                                     determined under Part 6.5 Division 2 of
                                                of fraud to circumvent the statutes
                                                                                          the California Insurance Code and the
Any transfer request must be in                 or regulations of the MRMIP. In
                                                                                          regulations of Title 10, Chapter 5.5.
writing to:                                     the event of fraud, the disenrollment
                                                could be retroactive to the               Subscribers may file an appeal with
 Managed Risk Medical Insurance Board
                                                subscriber’s original effective date.     MRMIB on the following issues:
          Benefits Division
           P.O. Box 2769                     Subscribers and dependents who have          1. Any action or failure to act which
    Sacramento, CA 95812-2769                been disenrolled for any reason may not         has occurred in connection with a
                                             re-enroll in the MRMIP for a period of          participating health plan’s coverage,
Subscribers who transfer enrollment are
                                             12 months.                                   2. Determination of an applicant’s or
not subject to pre-existing condition/
waiting period exclusions.                   Health Plan’s Dispute                           dependent’s eligibility,
                                             Resolution/Appeals                           3. Determination to disenroll a
Disenrollment
                                             If a subscriber is dissatisfied with any        subscriber or dependent, and
A subscriber and enrolled dependents
                                             action, or inaction, of the plan/provider    4. Determination to deny a subscriber’s
will be disenrolled from the MRMIP
                                             organization in which he/she is enrolled,       request or to grant a participating
when any of the following occur:
                                             the subscriber should first attempt to          health plan request to transfer the
1. The subscriber so requests in writing.    resolve the dispute with the participating      subscriber to a different participating
   Disenrollment will be effective at        plan/organization according to its              health plan.
   the end of the month in which the         established policies and procedures.
   request was received or disenrollment                                                  An appeal must be filed in writing
   will be effective at the end of the       Binding Arbitration                          within 60 calendar days of the action,
   month for which the subscriber                                                         failure to act, or receipt of notice of the
                                             Each plan has its own rules for resolving
   contribution was paid in full.                                                         decision being appealed to:
                                             disputes about the delivery of services
2. The subscriber fails to make              and other matters. Some plans say             Managed Risk Medical Insurance Board
   subscriber contributions in               you must use binding arbitration for                  Eligibility Division
   accordance with the MRMIP’s               disputes; others do not. Some plans                     P.O. Box 2769
   subscriber contribution payment           say that claims for malpractice must be          Sacramento, CA 95812-2769
   and grace period policies. The            decided by binding arbitration; others
                                                                                          Evidence of Coverage and Disclosure
   effective date of disenrollment           do not. If the plan you choose requires
                                                                                          Form or Certificate of Insurance
   for nonpayment of a subscriber            binding arbitration, you are giving up
                                                                                          Booklets
   contribution will be retroactive to       your right to a jury trial and cannot have
   the last day of the month for which       the dispute decided in court. To find out    Evidence of Coverage and Disclosure
   a subscriber contribution was paid        more about how a plan resolves disputes,     Form or Certificate of Insurance
   in full.                                  you can call the plan and ask for an         booklets are available from each health
                                             Evidence of Coverage or Certificate of       plan upon request. Please see each health
3. The subscriber fails to meet the          Insurance booklet.                           plan description for a phone number to
   residency requirement or becomes                                                       call to request one.
   eligible for Medicare Part A and Part
   B unless eligible solely because of
   end-stage renal disease. Subscribers
   must inform the MRMIP Enrollment


                                                                 6
Coordination of Benefits                     Your Rights Regarding How Your                Most individuals who become eligible
                                             Personal Information Is Used                  for Medicare because of age or disability
Participating health plans will coordinate
                                                                                           are entitled to purchase insurance
coverage of benefits with any other          You have the right to request the MRMIP
                                                                                           to supplement their Medicare for
health insurance you may have. The           to restrict the use of your personal
                                                                                           six months after they first purchase
MRMIP is secondary to other insurance        information. The Program may not agree
                                                                                           Medicare Part B, and under certain
coverage and by State law will only          to restrictions if it would interfere with
                                                                                           other circumstances. For individuals
pay after your other insurance has paid      normal operations and administration.
                                                                                           who become eligible for Medicare
(not including Medi-Cal and/or other         You also have the right to obtain a copy
                                                                                           because of a disability, the right to buy
State programs). Under the rules of the      or request a change to the personal
                                                                                           this supplemental insurance is the result
MRMIP, the benefits of this Program          information you provided to the MRMIP
                                                                                           of State law. You may call the Health
will not duplicate coverage you may have     as long as the Program retains such
                                                                                           Insurance Counseling and Advocacy
(whether you use it or not) under any        information. You have the right to obtain
                                                                                           Program (HICAP) program at
other program or plan.                       an explanation about how your personal
                                                                                           1-800-434-0222 for free information
                                             information was disclosed, other than the
Privacy Notification                                                                       and counseling about these rights.
                                             use of your information by MRMIP to
This notice describes how medical            carry out the operations of the Program.
information about you may be used and        MRMIP may revise the privacy practices
disclosed and how you can get access         described here. The Program will notify
to this information. Please review it        its subscribers by updating program
carefully.                                   handbooks or through direct mail notices
When you apply for the MRMIP,                (within 60 days) of such revisions. You
the information you provide in the           may complain to the MRMIB if you
application is reviewed by a private         believe your privacy rights have been
contractor. The private contractor is        violated by contacting:
hired by the State of California to assist    Managed Risk Medical Insurance Board
in the administration of the MRMIP.              MRMIP HIPAA Coordinator
The contractor uses your information                    P.O. Box 2769
to determine whether you are eligible            Sacramento, CA 95812-2769
for MRMIP. The contractor and the                      1-916-324-4695
State will use your information for
administration and evaluation of the         Under Age 65 Disabled Medicare
Program and for necessary purposes           Beneficiaries
authorized by law.
                                             You are ineligible for coverage through
If you are determined eligible for           MRMIP if you are eligible for Medicare
MRMIP, the contractor will send your         Part A and Part B, unless you are eligible
information to the health insurance          for Medicare solely because you have
plan that provides your information          end-stage renal disease.
to the provider that you select, so you
                                             You are required to inform the Program
can begin to receive health insurance
                                             when you become eligible for Medicare
coverage under that plan. Once you are
                                             Part A and Part B. Please contact
enrolled, your health plan will forward
                                             the Major Risk Enrollment Unit at
to the State information regarding the
                                             1-800-289-6574. “Eligible” for Part A
health care and services that you receive.
                                             means that you are not required to pay
Uses and disclosures that are not part       a premium for Part A. “Eligible” for
of the operations of the Program             Part B simply means that you have the
will only be made with your written          right to purchase Part B because you are
authorization or as required by law.         eligible for Part A. You are ineligible for
This authorization may later be revoked      MRMIP even if you choose not to pay
at your written request.                     the premium for Medicare Part B.


                                                                 7
                                         Anthem Blue Cross Preferred Provider Organization (PPO)

                                                                                                                                                                                   1-877-687-0549
                                                                                                                                                                          Call Monday through Friday
                                                                                                                                                                          from 8:30 a.m. to 7:00 p.m.

Plan Highlights                                                              greater share of the cost when you use a                                       • $25 office visit copayment when you
                                                                             nonparticipating provider because you will                                       use our in-network doctors.
Medical Services at Discounted Rates                                         be responsible for a larger coinsurance and
Anthem Blue Cross has found a way to                                                                                                                        • Yearly maximum copayment/
                                                                             any charges that exceed the fee schedule.                                        coinsurance limit for in-network
help control escalating medical expenses
for members. We have negotiated                                              Anthem Blue Cross contracts with most                                            providers per calendar year:
discounted rates with a network of                                           hospitals in California; however, benefits
                                                                                                                                                                − $2,500 per member
physicians and hospitals across the state.                                   are not provided for care furnished by
                                                                             the few hospitals without an agreement                                             − $4,000 per family
These providers form the Preferred
Provider Organization (PPO) plan. They                                       with Anthem Blue Cross (except care for                                        • $75,000 annual maximum for
give Anthem Blue Cross members a                                             medical emergencies).                                                            benefits paid per calendar year.
discount for care.                                                           How the Plan Works                                                             • $750,000 lifetime maximum for
Members must satisfy a $500 calendar                                         The Anthem Blue Cross PPO plan covers                                            benefits paid for each member in his/
year deductible before the plan will                                                                                                                          her lifetime.
                                                                             your medical and prescription expenses
begin paying for most covered services                                                                                                                    The Anthem Blue Cross PPO plan
                                                                             after a $500 calendar year deductible is
beginning each January 1st. Preventive                                                                                                                    includes the Anthem Blue Cross
                                                                             met for most covered services.
services are not subject to the calendar year
                                                                               • $500 Calendar Year Deductible                                            Prescription Drug Program with these
deductible. Once the deductible is met,
                                                                                 per member or per family. The                                            important features:
members pay only a $25 copayment for
office visits to doctors in the Anthem Blue                                      payments or incurred costs for                                               • Lower cost: Anthem Blue Cross has
Cross network or 15% of the discounted                                           services provided by in-network and                                            negotiated discounts with almost
rate, depending on the service. Once you                                         out-of-network providers for medical                                           90% of California retail pharmacies,
reach your yearly maximum copayment/                                             and prescription services excluding                                            including all of the major chain
coinsurance limit, Anthem Blue Cross                                             preventive care services.                                                      drugstores. You may choose any
pays 100% of the cost for in-network,                                          • Preventive Care Services                                                       pharmacy, but your costs are much
covered services for the rest of the calendar                                                                                                                   lower if you stay in the network
                                                                                 These services are covered even if
year. There are no claim forms to file when                                                                                                                     using participating providers.
                                                                                 you have not met the calendar year
you use in-network providers.                                                                                                                                 • Service: Network pharmacies are
                                                                                 deductible and do not apply towards
Advantages of Plan Providers                                                     the deductible:                                                                supported by an online electronic
                                                                                  Breast Exams, Pelvic Exams, Pap                                               network and will collect your
Access to One of the Largest Provider
                                                                                  Smears, and Mammograms for                                                    copayment when you pick up your
Networks in California
The Anthem Blue Cross PPO plan gives                                              Women, Human Papillomavirus                                                   prescription. No claim forms to file!
you access to quality care through our                                            (HPV) Screening Test, Ovarian and                                       Important Information
network of physicians, hospitals and                                              Cervical Cancer screening, Cytology
                                                                                                                                                          If you would like more information
selected ambulatory surgical centers,                                             Examinations, Family Planning
infusion therapy, and durable medical                                                                                                                     before you enroll, please call Anthem
                                                                                  Services, Health Education Services,
equipment providers. Using network                                                                                                                        Blue Cross Customer Service at
                                                                                  Periodic Health Examinations and
participating providers ensures maximum                                                                                                                   1-877-687-0549. Call Monday through
                                                                                  Laboratory Services in connection
member savings.                                                                                                                                           Friday from 8:30 a.m. to 7:00 p.m.
                                                                                  with them, Hearing and Vision Exams
   • Extensive provider network                                                   for Children, Newborn Blood Tests,                                      Please note that the information presented
     comprised of more than 40,000                                                Prenatal Care (care during pregnancy),                                  here is only a summary. The Anthem
     PPO physicians, 29,000 HMO                                                   Prostate Exams for Men, Sexually                                        Blue Cross plan for MRMIP is subject
     physicians and more than                                                     Transmitted Infections (STI) Tests,                                     to various limitations, exclusions and
     400 hospitals.                                                               Human Immunodeficiency Virus                                            conditions, as fully described in the
Benefits Still Available                                                          (HIV) Testing, Well-Baby and Well-                                      Evidence of Coverage. For exact terms and
Out-of-Network                                                                    Child Visits, Certain Immunizations                                     conditions of coverage, you should refer to
You can go outside the network and                                                for Children and Adults and Disease                                     the Evidence of Coverage booklet.
still receive benefits. You will pay a                                            Management Programs.

Anthem Blue Cross is the trade name of Blue Cross of California. Independent licensee of the Blue Cross Association. ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc.
The Blue Cross name and symbol are registered marks of the Blue Cross Association.
WellPoint NextRx is a registered service mark of WellPoint, Inc. Services are provided by a WellPoint PBM (either NextRx Services, Inc. or NextRx, LLC, as applicable).
WellPoint NextRx is an independent company and a division of WellPoint, Inc.
                                                                                                                8
                                                                                           Anthem Blue Cross PPO
                                                                                               Summary of Benefits
                                                                                                                                 What You Pay                                    What You Pay
  Type of Service                      Description of Service                                                                    Participating Provider                          Nonparticipating Provider
  Annual Deductible                    The amount that you must pay for covered services except for preventive                                                $500 per member
                                       care services before the plan will cover those services at the copayment or                                            (Subscriber only)
                                       coinsurance amount
                                                                                                                                                              $500 per family
                                                                                                                                                              (Subscriber + 1 or more dependents on the same policy)
  Copayment/                           Member’s amount due and payable to the provider of care                                                                See Below
  Coinsurance
  Yearly Maximum                       Member’s annual maximum copayment/coinsurance limit when using                            $2,500 per member                                    No yearly maximum copayment/coinsurance
  Copayment/                           participating providers in one calendar year                                              (Subscriber only)                                    limit for nonparticipating providers. You pay
  Coinsurance Limit                                                                                                                                                                   unlimited coinsurance.
                                                                                                                                 $4,000 per family
                                                                                                                                 (Subscriber + 1 or more dependents on the
                                                                                                                                 same policy)
                                       If nonparticipating providers are used, billed charges which exceed the customary and reasonable charges are the member’s
                                       responsibility and do not apply to the yearly maximum copayment/coinsurance limit
  Annual Benefit                       You must pay for all services received after the combined total of all
  Maximum                              benefits paid under the MRMIP reaches $75,000 in one calendar year for
                                       a member
  Lifetime Benefit                     You must pay for all services received after the combined total of all benefits
  Maximum                              paid under the MRMIP reaches $750,000 in a lifetime for a member
  Preventive Care                      Services                                                                                  15% of negotiated fee rate                           50% of customary and reasonable charges and
  Services**                                                                                                                                                                          any in excess
                                       Breast Exams, Pelvic Exams, Pap Smears, and Mammograms for Women, Human Papillomavirus (HPV) Screening Test,
                                       Ovarian and Cervical Cancer Screening, Cytology Examinations, Family Planning Services, Health Education Services,
                                       Periodic Health Examinations and Laboratory Services in connection with them, Hearing and Vision Exams for Children,
                                       Newborn Blood Tests, Prenatal Care (care during pregnancy), Prostate Exams for Men, Sexually Transmitted Infections
                                       (STI) Tests, Human Immunodeficiency Virus (HIV) Testing, Well-Baby and Well-Child Visits, Certain Immunizations
                                       for Children and Adults, and Disease Management Programs
  Hospital Services                    Inpatient medical services (semi-private room)                                            15% of negotiated fee rate                           All charges except for $650 per day

                                       Outpatient services; ambulatory surgical centers                                          15% of negotiated fee rate                           All charges except for $380 per day
                                       (No benefits are provided in a noncontracting hospital or noncontracting dialysis treatment center in California, except in
                                       the case of a medical emergency)
  Physician Office Visits              Services of a physician for medically necessary services                                  $25 office visit                                     50% of customary and reasonable charges and
                                                                                                                                                                                      any in excess
  Diagnostic X-ray and                 Outpatient diagnostic X-ray and laboratory services                                       15% of negotiated fee rate                           50% of customary and reasonable charges and
  Lab Services**                                                                                                                                                                      any in excess
  Prescription Drugs                   Maximum 30-day supply per prescription when filled at a                                   $5 for generic drugs                                 All charges except 50% of drug limited fee
                                       participating pharmacy                                                                    $15 for brand drugs                                  schedule for generic or brand name drugs

                                       60-day supply for mail order                                                              $5 for generic drugs through mail service
                                                                                                                                 prescription drug program (WellPoint NextRx )   SM

                                                                                                                                 $15 for brand drugs through mail service
                                                                                                                                 prescription drug program (WellPoint NextRx )   SM




  Durable Medical                      Must be certified by a physician and required for care of an illness or injury            15% of negotiated fee rate                           50% of customary and reasonable charges and
  Equipment and Supplies                                                                                                                                                              any in excess
  Pregnancy** and                      Inpatient normal delivery and complications of pregnancy                                  15% of negotiated fee rate                           All charges except for $650 per day for
  Maternity Care                                                                                                                                                                      hospital services
                                       Prenatal ** and postnatal care                                                            15% of negotiated fee rate                           50% of customary and reasonable charges and
                                                                                                                                                                                      any in excess
  Ambulance Services                   Ground or air ambulance to or from a hospital for medically                               15% of negotiated fee rate                           15% of customary and reasonable charges and
                                       necessary services                                                                                                                             any in excess
  Emergency Health                     Initial treatment of an acute serious illness or accidental injury. Includes              15% of negotiated fee rate                           15% of customary and reasonable charges or billed
  Care Services*                       hospital, professional, and supplies                                                                                                           charges, whichever is less plus any charges in excess
                                                                                                                                                                                      of customary and reasonable for the first 48 hours
  Mental Health                        Inpatient basic mental health care services up to 10 days each calendar year              15% of negotiated fee rate and all costs for         All charges except for $175 per day up to 10
  Care Services*                                                                                                                 stays over 10 days except for SMI and SED            days. In addition, all costs for stays over 10 days
                                                                                                                                 services.                                            except for SMI and SED services.

                                       Outpatient basic mental health care visits up to 15 visits each calendar year             15% of negotiated fee rate for 15 visits per         50% of customary and reasonable charges and any
                                       *Unlimited inpatient days and outpatient visits for Severe Mental Illnesses               year. All costs for over 15 visits except for        in excess. In addition, all costs over 15 visits except
                                       (SMI) and Serious Emotional Disturbances (SED) in children.                               SMI and SED services.                                for SMI and SED services.
  Home Health Care                     Home health services through a home health agency or visiting                             15% of negotiated fee rate                           50% of customary and reasonable charges and
                                       nurse association                                                                                                                              any in excess
  Hospice                              Hospice care for members who are not expected to live for more than                       15% of negotiated fee rate                           50% of customary and reasonable charges and
                                       12 months                                                                                                                                      any in excess
  Skilled Nursing                      Skilled nursing care                                                                      Not covered unless Anthem Blue Cross recommends as a medically appropriate more cost-
  Facilities                                                                                                                     effective alternative plan of treatment
  Infusion Therapy*                    Therapeutic use of drugs, or other substances ordered by a physician and                  15% of negotiated fee rate                           You pay all charges in excess of $500 per day
                                       administered by a qualified provider                                                                                                           for all infusion therapy related administrative,
                                                                                                                                                                                      professional, and drugs
  Physical/Occupational/               Services of physical therapists, occupational therapists, and speech                      15% of negotiated fee rate                           You pay all charges except for $25 per visit
  Speech Therapy                       therapists as medically appropriate on an outpatient basis

* For exact terms and conditions of coverage, you should refer to your Evidence of Coverage booklet.
** These preventive care services are covered even if you have not met the calendar year deductible and do not apply towards the deductible.

                                                                                                                         9
                                                                                        A Culture of Caring for over 35 Years!

                                                                                                Member Call Center
                                                                                            1-877-661-6230 (Press 2)
                                                                                                        Monday through Friday
                                                                                                             8 a.m. to 5 p.m.

Plan Highlights                            routine care, and referrals for specialty   Deductible
                                           care that you need.
Contra Costa Health Plan (CCHP),                                                       There will be an annual $500 deductible
founded in 1973, is stable and             CCHP’s other “provider network” is          that accrues on a calendar year.
secure. CCHP is sponsored by the           the Community Provider Network.             Only payments or incurred costs for
County of Contra Costa, is licensed        With offices throughout Contra Costa        Inpatient Hospital services provided
by the California State Department         County, you will easily be able to          by In-Network and Out-of-Network
of Managed Health Care, and is a           select a Primary Care Provider (PCP)        Providers apply toward the $500 annual
federally qualified Health Maintenance     near you. These community providers         deductible. You do not have to meet
Organization. Our over 65,000              are affiliated with one or more of six      a deductible before receiving coverage
members, therefore, have the assurance     hospitals in the area. The Contra Costa     for other benefits. Please refer to the
of knowing that CCHP must conform          Regional Medical Center’s specialty         “Benefits and Cost Sharing” section of
to the highest standards of care.          services are also available to providers    your Evidence of Coverage booklet for
                                           and members of this network.                more information.
Our members appreciate
  • Affordable, quality care, plus         How the Plan Works                          Your Copayments and Prescription
    excellent service                      CCHP is available to MRMIP                  Coverage
  • A comprehensive benefit package        subscribers who live in Contra              You will be responsible for paying a
                                           Costa County.                               copayment for some services, such as
  • Neighborhood Health Centers
                                           When you join CCHP, we encourage            doctor visits and hospital stays. You
    with extended hours for primary
                                           you to call our Member Services             will be charged 20% of the cost of your
    and urgent care services, and
                                           Department. Our friendly Member             prescriptions, which must be obtained at
    access to the Contra Costa Regional
                                           Services Representatives will take as       Plan-authorized pharmacies.
    Medical Center
                                           much time as you need to help you           The maximum amount of copayments
  • An extensive network of
                                           select your PCP and with any other          you will pay is $2,500 per person, or
    community primary care and
                                           questions you may have about how            $4,000 per family, in any calendar year.
    specialty physicians, and contracted
                                           to access your plan services. You can       Maximum Benefits
    community hospitals
                                           change your PCP at any time by calling
  • A 24-hour Advice Nurse service                                                     Annual maximum benefits are $75,000
                                           Member Services and choosing another
    available 365 days a year                                                          per covered person, with a maximum
                                           provider from either provider network.
                                                                                       lifetime benefit of $750,000.
  • Emergency services covered             The 24-hour Advice Nurse service is
    worldwide                              available to members every day of the       Important Information
Plan Providers                             year. Advice Nurses offer confidential      To learn more about Contra Costa
                                           and professional health advice and          Health Plan’s MRMIP, call our
When you select CCHP for yourself          important information about preventive      Marketing Department at
and your family, you are gaining access    care services.                              1-800-211-8040 (press 6).
to over 2,000 providers and specialists.
CCHP offers a choice of two “provider      All new members will receive
networks”: One, our Regional Medical       Informational Materials, which include a    The information presented on this page
Center Network, offers primary care        Member Handbook, Provider Directory,        is only a summary. For exact terms and
and access to specialty care through       Combined Evidence of Coverage and           conditions please refer to the Evidence of
eight Health Centers and at the newest     Disclosure document, and a Health           Coverage booklet.
hospital in the East Bay, the Contra       Plan membership ID card. Call CCHP
Costa Regional Medical Center in           Member Services at 1-877-661-6230
Martinez. You simply select the Health     (press 2) with any questions about
Center most conveniently located for       your membership.
you, and your doctor there will make
sure you get all the preventive care,

                                                               10
                                                              Contra Costa Health Plan

                                                                  Summary of Benefits
                                                                                                                                   What You Pay
 Type of Service                            Description of Service                                                                 Contra Costa Health Plan Provider
 Calendar Year Deductible                   The amount you must pay for Inpatient Hospital Services (including Inpatient           $500 per household
                                            Mental Health Services and Inpatient Emergency Services) before the plan will
                                            cover those services at the copayment amount within that calendar year
 Copayment                                  Your out-of-pocket expense for the cost of authorized and covered expenses             Inpatient medical $200/day
                                                                                                                                   Inpatient psychiatric $200/day
                                                                                                                                   Inpatient maternity $200/day
                                                                                                                                   Outpatient ER $25/visit
                                                                                                                                   Outpatient visits $15/visit
 Out-of-Pocket Maximum                      The annual maximum out-of-pocket expense you’re responsible for (excluding             $2,500 (per covered person)
                                            unauthorized or noncovered services)                                                   $4,000 (per family)
 Annual Benefit Maximum                     You must pay for all services received after the combined total of all benefits paid
                                            under the MRMIP reaches $75,000 in one calendar year for a member
 Lifetime Benefit Maximum                   You must pay for all services received after the combined total of all benefits paid
                                            under the MRMIP reaches $750,000 in a lifetime for a member
 Hospital Services                          Semi-private room and board, and all medically necessary inpatient services and        $200/day
                                            supplies including inpatient visits by physicians                                      (subject to Inpatient Hospital Services deductible)
 Physician Care                             Medical and surgical outpatient services performed or authorized by Contra             Office visits $15/visit
                                            Costa Health Plan provider                                                             Well baby $15/visit
                                                                                                                                   Physical exams $15/visit
 Preventive Services                        •   Breast Exams, Pelvic Exams, Pap Smears, and Mammograms for Women                   $15/visit
                                            •   Cytology Examinations                                                              These services are not subject to the annual
                                            •   Family Planning Services                                                           deductible and your applicable copayment or
                                            •   Health Education Services                                                          coinsurance will apply.
                                            •   Periodic Health Examinations
                                            •   Hearing Tests and Eye Exams
                                            •   Newborn Blood Tests
                                            •   Prenatal Care (care during pregnancy)
                                            •   Prostate Exams for Men
                                            •   Venereal Diseases Tests
                                            •   Well-Baby and Well-Child Visits
                                            •   Immunizations for Children and Adults
 Diagnostic X-ray and Lab Tests             Inpatient and outpatient diagnostic X-ray and laboratory tests                         -0-
 Prescription Drugs                         Drugs prescribed by a physician                                                        20% of the cost of prescription obtained at
                                                                                                                                   Plan-authorized pharmacies
 Durable Medical Equipment and Supplies     Purchase or rental as authorized by Contra Costa Health Plan and required for          -0-
                                            care of an illness or injury
 Maternity Care                             Treated as any other medical condition:
                                             Inpatient                                                                             $200/day
                                             Outpatient                                                                            $15/visit
 Ambulance                                  Ambulance service when required for an emergency or approved by a Contra               $15 copay
                                            Costa Health Plan physician
 Emergency Care Services                    Services in an emergency room for emergency care only – nonemergency care              $25/visit waived if admitted to a hospital
                                            not covered                                                                            (subject to Inpatient Hospital Services
                                                                                                                                   deductible.)
 Mental Health Care Services                Inpatient visits up to 10 days per calendar year                                       $200/day
                                            Outpatient visits up to 15 visits per calendar year                                    $15/visit
                                            Unlimited inpatient days and outpatient visits for Severe Mental Illnesses and         (Inpatient Services are subject to Inpatient
                                            Serious Emotional Disturbances in children                                             Hospital Services deductible.)
 Home Health Care/Home Hospice Care         Medically necessary visits when authorized for diagnostic and treatment service        -0-
                                            and nursing care
 Skilled Nursing Services                   Provided only when Contra Costa Health Plan authorizes as medically necessary          -0-
                                            and more cost effective
 Speech/Physical/Occupational Therapy       Medical rehabilitation and the services of occupational therapists, physical           $15/visit
                                            therapists, and speech therapists as appropriate on an outpatient basis
 Other                                      Blood and blood plasma, 24-hour advice                                                 -0-
                                            Nurse, member services, health education, and case management

Note: All benefits are covered by Contra Costa Health Plan only if they are prescribed or directed by a Contra Costa Health Plan physician.
Other Plan limitations and exclusions apply. Please refer to the Evidence of Coverage for disclosure of Plan limitations and exclusions.
Contra Costa Health Plan is available only to residents in Contra Costa County.




                                                                                      11
                                                                                                                 1-800-464-4000
                                                                                                           Weekdays 7 a.m. to 7 p.m.
                                                       Northern California                                 Weekends 7 a.m. to 3 p.m.
                                                                                                                  (except Holidays)

Plan Highlights                                   publication is a directory of all            • Referrals to specialist – As a group
                                                  Northern California facilities and             practice, our physicians can easily
Kaiser Permanente’s medical care program
                                                  services available to our members.             refer you to a specialist within
offers the kind of benefits you’ve been
                                                                                                 your service area, at another Kaiser
looking for:                                   Plan Providers                                    Permanente service area.
Convenient Care                                 • When you select Kaiser Permanente            • Deductible – Kaiser Permanente
  • You can receive care at any of our            as your MRMIP Plan provider, your              has an annual $500 deductible you
     locations in Northern California,            medical care is provided or arranged           must satisfy before the plan will
     close to work or close to home – or          by Kaiser Permanente physicians at             begin paying for covered services.
     both.                                        Kaiser Permanente medical facilities.          You are responsible for charges for
                                                  Our dedicated physicians represent             certain covered services subject to the
  • MRMIP subscribers can get care in
                                                  virtually all major medical and surgical       deductible and Kaiser Permanente will
     the following Northern California
                                                  specialties, and work together in one          not cover these services until you meet
     counties (Alameda, Amador, Contra
                                                  of the nation’s largest medical groups         the deductible. The only payments
     Costa, El Dorado, Fresno, Kings,
                                                  to care for you and your family.               that count toward a deductible are
     Madera, Marin, Mariposa, Napa,
     Placer, Sacramento, San Francisco,         • We’re proud of the caliber of our              those you make for covered services
     San Joaquin, San Mateo, Santa Clara,         physicians. Many of them graduated             that are subject to the deductible.
     Solano, Sonoma, Sutter, Tulare, Yolo         from top medical schools, such as:             After you meet the deductible and
     and Yuba).                                   Harvard, Yale, Stanford, and UCLA.             for the remainder of the calendar
  • Please see the chart at the back of this    • You can choose your own Kaiser                 year, you pay only the applicable
     brochure for the specific ZIP codes          Permanente primary care physician              copayment or coinsurance subject to
     open to MRMIP Plan enrollment.               who will work with you to coordinate           the annual out-of-pocket maximum.
                                                  all your health care needs. You or             Payments for services provided by
Broad-based Care
                                                  your family may select a different             In-Network and Out-of-Network
  • Your family (including spouse and             physician at any time – your choice is         Providers and prescription payments
     unmarried children under age 23)             never restricted to any one physician          apply toward the $500 annual
     are also eligible for coverage under         or facility.                                   deductible. Most Preventive Care
     the MRMIP Plan. Your annual                                                                 Services are covered even if you have
                                                • Emergency and urgent care is available
     maximum benefit total is $75,000 per                                                        not met your deductible and do
                                                  from Kaiser Permanente 24 hours a
     covered individual, and the lifetime                                                        not apply toward the $500 annual
                                                  day, seven days a week.
     maximum benefit is $750,000 per                                                             deductible.
     covered individual.                       How the Plan Works                              • Copayment – The maximum of
  • In addition to primary care visits,         • Always carry your Kaiser                       out-of-pocket expenses you pay
     your MRMIP Plan includes specialty           Permanente ID Card. It has                     in a calendar year are $2,500 per
     care services, lab tests, X-rays and         important information which will               individual and/or $4,000 per family.
     health education classes.                    assist you in making appointments
A Plan That’s Easy to Use                         and utilizing services. You can make       Important Information
  • You do not need to file claim                 an appointment by calling one of our       For more information about the Northern
     forms for services received at Kaiser        convenient appointment centers.            California Kaiser Permanente MRMIP
     Permanente facilities.                     • Laboratories, X-ray services, and          Plan program, please call our Member
                                                  pharmacies – These are located             Service Call Center at 1-800-464-4000.
  • When you present your Kaiser card at
                                                  at each medical center (many               Please note that the information presented
     one of our Health Plan facilities, our
                                                  pharmacies are open 24 hours).             on these pages is only a summary of the
     computerized registration system will
                                                • Urgent care is available on a walk-in      Kaiser Permanente MRMIP Plan for
     identify your benefits and copayments
     as described on the next page.               basis at each Medical Center. Medical      Northern California. For exact terms and
                                                  advice by phone and emergency              conditions of coverage, you should refer to
  • Upon enrollment in the MRMIP                                                             the Evidence of Coverage booklet.
     Plan, you will receive The Guidebook         services are available 24 hours a day,
     to Kaiser Permanente Services. This          seven days a week.
                                                                  12
                                                  Kaiser Permanente Northern California

                                                                   Summary of Benefits
 Type of Service                         Description of Service                                                                       What You Pay
 Annual Deductible                       The amount that you must pay before Kaiser Permanente assumes liability for the              $500 per household
                                         remaining cost of covered services, except for Preventive Care Services
 Copayment                               Your cost of covered services                                                                See specific service
 Out-of-Pocket Maximum                   The maximum amount you’re responsible for paying for covered services per calendar           $2,500 (per covered person)
                                         year                                                                                         $4,000 (per covered family)
 Annual Benefit Maximum                  You must pay for all services received after the combined total of all benefits paid under
                                         the MRMIP reaches $75,000 in one calendar year for a member
 Lifetime Benefit Maximum                You must pay for all services received after the combined total of all benefits paid under
                                         the MRMIP reaches $750,000 in a lifetime for a member
 Hospital Services                       Room and board, anesthesia, X-rays, lab tests, and drugs                                     $200 copay per inpatient day
 Physician Care                          Primary and specialty care visits                                                            $20 copay per office visit
                                         Allergy injections                                                                           $3 copay per injection
 Preventive Care Services*               Flexible sigmoidoscopies                                                                     $20 copay per visit
                                         Vaccines                                                                                     No charge
                                         Mammograms                                                                                   $5 per visit
                                         Routine physical examinations, including hearing and vision screenings                       $20 copay per office visit
                                         Scheduled prenatal visits                                                                    $15 copay per office visit
                                         Well-child preventive care visits (0-23 months)                                              $15 copay per office visit
 Diagnostic X-Ray and                    X-rays and ultraviolet light therapy                                                         $5 per visit
 Laboratory Tests                        The following Laboratory Tests:
                                           Cervical cancer screening                                                                  $5 per visit
                                           Cholesterol tests (lipid profile)                                                          $5 per visit
                                           Diabetes screening (fasting blood glucose tests)                                           $5 per visit
                                           Fecal occult blood tests                                                                   No charge
                                           HIV tests                                                                                  $5 per visit
                                           Prostate specific antigen tests                                                            $5 per visit
                                           Venereal diseases tests                                                                    $5 per visit
 Prescription Drugs                      Drugs prescribed by a plan physician and obtained at a plan pharmacy in accord with          $10 generic for up to a 100-day supply
                                         formulary guidelines                                                                         $35 brand for up to a 100-day supply

 Durable Medical Equipment, Supplies     Durable medical equipment when prescribed by a plan physician and obtained from              20% of member rate
                                         plan providers through Kaiser Permanente                                                     No charge during hospital stay
 Prosthetic Devices and Braces           Prosthetic devices and braces when prescribed by a plan physician and obtained from          No charge
                                         plan providers through Kaiser Permanente

 Maternity Care                          Prenatal* and postnatal care                                                                 $15 copay per office visit
                                         Inpatient care, complications of pregnancy, C-section                                        $200 copay per inpatient day

 Ambulance                               Ambulance services                                                                           $75 per trip
 Emergency Care Services                 Emergency department visits                                                                  $100 copay per incident (waived if admitted
                                                                                                                                      and hospitalization copays apply)
 Mental Health Care Services             Inpatient visits up to 10 days per calendar year                                             $200 copay per inpatient day
                                         Outpatient visits up to 15 visits per calendar year                                          $20 copay per visit
                                         Unlimited inpatient days and outpatient visits for Severe Mental Illnesses and Serious
                                         Emotional Disturbances in children

 Home Health Care/Hospice Care           Medically necessary visits by home health personnel up to 100 visits per year                No charge
                                         Hospice care                                                                                 No charge

 Skilled Nursing Services                Up to 100 days per benefit period                                                            No charge up to 100 days per benefit period

 Speech/Physical/Occupational            Outpatient medical rehabilitation and the services of an occupational therapist, physical    $20 copay per visit
 Therapy                                 therapists, and speech therapists
                                         Inpatient                                                                                    No charge

*Covered Preventive Care Services described above are not subject to the annual deductible.

Note: All care must be prescribed by and received from The Permanente Medical Group (TPMG) physician, or a physician to whom TPMG physician has referred
you for specific care. Any care received outside of Kaiser Permanente Northern California Region is not covered, with the exception of emergencies.

This chart does not describe benefits. To learn what is covered for each benefit (including exclusions and limitations) and additional benefits not included in this
summary, please refer to the Evidence of Coverage for this plan.




                                                                                      13
                                                                                                              1-800-464-4000
                                                                                                         Weekdays 7 a.m. to 7 p.m.
                                                                                                         Weekends 7 a.m. to 3 p.m.
                                                       Southern California                                      (except Holidays)

Plan Highlights                                Plan Providers                                • Referrals to specialists – As a
                                                                                               group practice, our physicians can
Kaiser Permanente’s medical care                • When you select Kaiser Permanente
                                                                                               easily refer you to a specialist within
program offers the kind of benefits               as your MRMIP Plan provider, your
                                                                                               your service area, at another Kaiser
you’ve been looking for:                          medical care is provided or arranged
                                                                                               Permanente service area.
Convenient Care                                   by Kaiser Permanente physicians
                                                  at Kaiser Permanente medical               • Deductible – Kaiser Permanente
  • You can receive care at any of our                                                         has an annual $500 deductible
                                                  facilities. Our dedicated physicians
    locations in Southern California, close                                                    you must satisfy before the plan
                                                  represent virtually all major medical
    to work or close to home – or both.                                                        will begin paying for covered
                                                  and surgical specialties, and work
  • MRMIP subscribers can get care in             together in one of the nation’s              services. You are responsible for
    parts of seven Southern California            largest medical groups to care for           charges for certain covered services
    counties (Kern, Los Angeles, Orange,          you and your family.                         subject to the deductible and
    Riverside, San Bernardino, San                                                             Kaiser Permanente will not cover
                                                • We’re proud of the caliber of
    Diego, and Ventura).                                                                       these services until you meet the
                                                  our physicians. Many of them
  • Please see the chart at the back of this                                                   deductible. The only payments that
                                                  graduated from top medical schools,
    brochure for the specific ZIP codes                                                        count toward a deductible are those
                                                  such as: Harvard, Yale, Stanford,
    open to MRMIP Plan enrollment.                                                             you make for covered services that
                                                  and UCLA.
                                                                                               are subject to the deductible.
Broad-based Care                                • You can choose your own Kaiser
                                                                                               After you meet the deductible and
  • Your family (including spouse                 Permanente primary care physician
                                                                                               for the remainder of the calendar
    and unmarried children under age              who will work with you to
                                                                                               year, you pay only the applicable
    23) are also eligible for coverage            coordinate all your health care needs.
                                                                                               copayment or coinsurance subject to
    under the MRMIP Plan. Your                    You or your family may select a
                                                                                               the annual out-of-pocket maximum.
    annual maximum benefit total is               different physician at any time –
                                                                                               Payments for services provided by
    $75,000 per covered individual, and           your choice is never restricted to any
                                                                                               In-Network and Out-of-Network
    the lifetime maximum benefit is               one physician or facility.
                                                                                               Providers and prescription payments
    $750,000 per covered individual.            • Emergency and urgent care is                 apply toward the $500 annual
  • In addition to primary care visits,           available from Kaiser Permanente             deductible. Most Preventive Care
    your MRMIP Plan includes specialty            24 hours a day, seven days a week.           Services are covered even if you
    care services, lab tests, X-rays and                                                       have not met your deductible and
    health education classes.
                                               How the Plan Works
                                                                                               do not apply towards the $500
                                                • Always carry your Kaiser                     annual deductible.
A Plan That’s Easy to Use
                                                  Permanente ID Card. It has
  • You do not need to file claim forms           important information which will           • Copayment – The maximum
    for services received at Kaiser               assist you in making appointments            out-of-pocket expenses you pay
    Permanente facilities.                        and utilizing services. You can make         in a calendar year are $2,500 per
                                                  an appointment by calling one of             individual and/or $4,000 per family.
  • When you present your Kaiser card at
    one of our Health Plan facilities, our        our convenient appointment centers.      Important Information
    computerized registration system will       • Laboratories, X-ray services, and        For more information about the Southern
    identify your benefits and copayments         pharmacies – These are located           California Kaiser Permanente MRMIP
    as described on the next page.                at each medical center (many             Plan program, please call our Member
  • Upon enrollment in the MRMIP                  pharmacies are open 24 hours).           Service Call Center at 1-800-464-4000.
    Plan, you will receive The                  • Urgent care is available on a walk-in    Please note that the information presented
    Guidebook to Kaiser Permanente                basis at each Medical Center.            on these pages is only a summary of the
    Services. This publication is a               Medical advice by phone and              Kaiser Permanente MRMIP Plan for
    directory of all Southern California          emergency services are available 24      Southern California. For exact terms and
    facilities and services available to          hours a day, seven days a week.          conditions of coverage, you should refer to
    our members.                                                                           the Evidence of Coverage booklet.
                                                                 14
                                                    Kaiser Permanente Southern California

                                                                      Summary of Benefits
 Type of Service                      Description of Service                                                                           What You Pay
 Annual Deductible                    The amount that you must pay before Kaiser Permanente assumes liability for the                  $500 per household
                                      remaining cost of covered services, except for Preventive Care Services
 Copayment                            Your cost of covered services                                                                    See specific service
 Out-of-Pocket Maximum                The maximum amount you’re responsible for paying for covered services per calendar year          $2,500 (per covered person)
                                                                                                                                       $4,000 (per covered family)
 Annual Benefit Maximum               You must pay for all services received after the combined total of all benefits paid under the
                                      MRMIP reaches $75,000 in one calendar year for a member
 Lifetime Benefit Maximum             You must pay for all services received after the combined total of all benefits paid under the
                                      MRMIP reaches $750,000 in a lifetime for a member
 Hospital Services                    Room and board, anesthesia, X-rays, lab tests and drugs                                          $200 copay per inpatient day
 Physician Care                       Primary and specialty care visits                                                                $20 copay per office visit
                                      Allergy injections                                                                               $3 copay per injection
 Preventive Care Services*            Flexible sigmoidoscopies                                                                         $20 copay per visit
                                      Vaccines                                                                                         No charge
                                      Mammograms                                                                                       $5 per visit
                                      Routine physical examinations, including hearing and vision screenings                           $20 copay per office visit
                                      Scheduled prenatal visits                                                                        $15 copay per office visit
                                      Well-child preventive care visits (0-23 months)                                                  $15 copay per office visit
 Diagnostic X-Ray and Laboratory      X-rays and ultraviolet light therapy                                                             $5 per visit
 Tests                                The following Laboratory Tests:
                                        Cervical cancer screening                                                                      $5 per visit
                                        Cholesterol tests (lipid profile)                                                              $5 per visit
                                        Diabetes screening (fasting blood glucose tests)                                               $5 per visit
                                        Fecal occult blood tests                                                                       No charge
                                        HIV tests                                                                                      $5 per visit
                                        Prostate specific antigen tests                                                                $5 per visit
                                        Venereal diseases tests                                                                        $5 per visit
 Prescription Drugs                   Drugs prescribed by a plan physician and obtained at a plan pharmacy in accord with              $10 generic for up to a 100-day supply
                                      formulary guidelines                                                                             $35 brand for up to a 100-day supply
 Durable Medical Equipment,           Durable medical equipment when prescribed by a plan physician and obtained from plan             20% of member rate
 Supplies                             providers through Kaiser Permanente                                                              No charge during hospital stay
 Prosthetic Devices and Braces        Prosthetic devices and braces when prescribed by a plan physician and obtained from plan         No charge
                                      providers through Kaiser Permanente

 Maternity Care                       Prenatal* and postnatal care                                                                     $15 copay per office visit
                                      Inpatient care, complications of pregnancy, C-section                                            $200 copay per inpatient day
 Ambulance                            Ambulance services                                                                               $75 per trip
 Emergency Care Services              Emergency department visits                                                                      $100 copay per incident (waived if admitted
                                                                                                                                       and hospitalization copays apply)

 Mental Health Care Services          Inpatient visits up to 10 days per calendar year                                                 $200 copay per inpatient day
                                      Outpatient visits up to 15 visits per calendar year                                              $20 copay per visit
                                      Unlimited inpatient days and outpatient visits for Severe Mental Illnesses and Serious
                                      Emotional Disturbances in children
 Home Health Care/Hospice Care        Medically necessary visits by home health personnel up to 100 visits per year                    No charge
                                      Hospice care                                                                                     No charge
 Skilled Nursing Services             Up to 100 days per benefit period                                                                No charge up to 100 days per benefit period

 Speech/Physical/                     Outpatient medical rehabilitation and the services of an occupational therapist, physical        $20 copay per visit
 Occupational Therapy                 therapists, and speech therapists
                                      Inpatient                                                                                        No charge

*Covered Preventive Care Services described above are not subject to the annual deductible.

Note: All care must be prescribed by and received from the Southern California Kaiser Permanente Medical Group (SCPMG) physician, or a physician to whom a
SCPMG physician has referred you for specific care. Any care received outside of Kaiser Permanente Southern California Region is not covered, with the exception of
emergencies.

This chart does not describe benefits. To learn what is covered for each benefit (including exclusions and limitations) and additional benefits not included in this
summary, please refer to the Evidence of Coverage for this plan.




                                                                                       15
California Major Risk Medical Insurance Program
Monthly Subscriber Contributions
Area 1
Counties: Alpine, Amador, Butte, Calaveras, Colusa, Del Norte, El Dorado, Glenn, Humbolt, Inyo, Kings, Lake, Lassen,
Mendocino, Modoc, Mono, Monterey, Nevada, Placer, Plumas, San Benito, Shasta, Sierra, Siskiyou, Sutter, Tehama,
Trinity, Tulare, Tuolumne, Yolo, Yuba.
   Below are available health plans listed by service area and ZIP codes. Some health plans may not be available in your area.
Rating Group                                                    Age                              Anthem                  KPNC1
Subscriber Only                                                 <15                              $310.20                 $242.30
                                                               15-29                             $457.80                 $305.38
                                                               30-34                             $571.20                 $360.84
                                                               35-39                             $621.60                 $387.48
                                                               40-44                             $698.70                 $434.79
                                                               45-49                             $734.90                 $477.70
                                                               50-54                             $878.00                 $551.63
                                                               55-59                            $1,020.50                $631.49
                                                               60-64                            $1,184.40                $699.51
                                                               65-69                            $1,326.60               $1,066.88
                                                               70-74                            $1,397.60               $1,126.29
                                                                >74                             $1,480.50               $1,194.93
Subscriber &                                                    <15                              $530.80                 $483.48
1 Dependent                                                    15-29                             $918.50                 $644.80
                                                               30-34                            $1,029.90                $733.53
                                                               35-39                            $1,099.10                $808.95
                                                               40-44                            $1,198.90                $887.33
                                                               45-49                            $1,293.20                $930.23
                                                               50-54                            $1,540.90               $1,109.18
                                                               55-59                            $1,826.90               $1,228.98
                                                               60-64                            $2,096.40               $1,399.04
                                                               65-69                            $2,347.90               $1,892.08
                                                               70-74                            $2,473.70               $1,996.33
                                                                >74                             $2,620.50               $2,111.29
Subscriber &                                                    <15                              $741.00                 $825.63
2 or More Dependents                                           15-29                            $1,290.40               $1,055.93
                                                               30-34                            $1,461.00               $1,277.76
                                                               35-39                            $1,545.10               $1,277.76
                                                               40-44                            $1,588.90               $1,296.99
                                                               45-49                            $1,755.70               $1,296.99
                                                               50-54                            $1,988.30               $1,434.53
                                                               55-59                            $2,233.90               $1,434.53
                                                               60-64                            $2,539.10               $1,620.88
                                                               65-69                            $2,843.80               $2,458.61
                                                               70-74                            $2,996.20               $2,599.10
                                                                >74                             $3,173.90               $2,749.68
1   Kaiser Permanente Northern California available only to residents in these ZIP codes in these counties:
       Amador–95640 and 95669;
       El Dorado–95613-14, 95619, 95623, 95633-35, 95651, 95664, 95667, 95672, 95682, and 95762;
       Kings–93230 and 93232;
       Placer–95602-04, 95648, 95650, 95658, 95661, 95663, 95677-78, 95681, 95703, 95722, 95736, 95746-47, and 95765;
       Sutter–95659, 95668, 95674, and 95676;
       Tulare–93261, 93618, 93666, and 93673;
       Yolo–95605, 95607, 95612, 95616-18, 95645, 95691, 95694-95, 95697-98, 95776, and 95798-99;
       Yuba–95692, 95903, and 95961.




Anthem = Anthem Blue Cross PPO
KPNC = Kaiser Permanente Northern California
                                                                           16
California Major Risk Medical Insurance Program
Monthly Subscriber Contributions
Area 2
Counties: Fresno, Imperial, Kern, Madera, Mariposa, Merced, Napa, Sacramento, San Joaquin, San Luis Obispo, Santa
Cruz, Solano, Sonoma, Stanislaus.
   Below are available health plans listed by service area and ZIP codes. Some health plans may not be available in your area.
Rating Group                                                       Age                                    Anthem                           KPNC2/KPSC3
Subscriber Only                                                    <15                                   $298.30                                $242.30
                                                                  15-29                                  $440.60                                $305.38
                                                                  30-34                                  $549.80                                $360.84
                                                                  35-39                                  $598.10                                $387.48
                                                                  40-44                                  $672.30                                $434.79
                                                                  45-49                                  $707.20                                $477.70
                                                                  50-54                                  $844.90                                $551.63
                                                                  55-59                                  $982.10                                $631.49
                                                                  60-64                                 $1,139.80                               $699.51
                                                                  65-69                                 $1,276.60                              $1,066.88
                                                                  70-74                                 $1,345.00                              $1,126.29
                                                                   >74                                  $1,424.80                              $1,194.93
Subscriber &                                                       <15                                   $520.70                                $483.48
1 Dependent                                                       15-29                                  $885.70                                $644.80
                                                                  30-34                                  $999.10                                $733.53
                                                                  35-39                                 $1,065.40                               $808.95
                                                                  40-44                                 $1,166.80                               $887.33
                                                                  45-49                                 $1,255.70                               $930.23
                                                                  50-54                                 $1,500.30                              $1,109.18
                                                                  55-59                                 $1,781.70                              $1,228.98
                                                                  60-64                                 $2,028.60                              $1,399.04
                                                                  65-69                                 $2,272.10                              $1,892.08
                                                                  70-74                                 $2,393.80                              $1,996.33
                                                                   >74                                  $2,535.80                              $2,111.29
Subscriber &                                                       <15                                   $718.70                                $825.63
2 or More Dependents                                              15-29                                 $1,241.90                              $1,055.93
                                                                  30-34                                 $1,411.90                              $1,277.76
                                                                  35-39                                 $1,486.90                              $1,277.76
                                                                  40-44                                 $1,529.10                              $1,296.99
                                                                  45-49                                 $1,689.70                              $1,296.99
                                                                  50-54                                 $1,913.40                              $1,434.53
                                                                  55-59                                 $2,149.90                              $1,434.53
                                                                  60-64                                 $2,443.60                              $1,620.88
                                                                  65-69                                 $2,736.90                              $2,458.61
                                                                  70-74                                 $2,883.50                              $2,599.10
                                                                   >74                                  $3,054.50                              $2,749.68
2   Kaiser Permanente Northern California available only to residents in these               Sonoma–94922-23, 94927-28, 94931, 94951-55, 94972, 94975,
    ZIP codes in these counties:                                                             94999,95401-07, 95409, 95416, 95419, 95421, 95425, 95430-31, 95433,
       Fresno–93242, 93602, 93606-07, 93609, 93611-13, 93616, 93619, 93624-                  95436, 95439, 95441-42, 95444, 95446, 95448, 95450, 95452, 95462,
       27, 93630-31, 93646, 93648-52, 93654, 93656-57, 93660, 93662, 93667-                  95465, 95471-73, 95476, 95486-87, and 95492.
       68, 93675, 93701-12, 93714-18, 93720-30, 93741, 93744-45, 93747,               3   Kaiser Permanente Southern California available only to residents in these
       93750, 93755, 93760-61, 93764-65, 93771-80, 93784, 93786, 93790-94,                ZIP codes in these counties:
       93844, and 93888;                                                                     Kern–93203, 93205-06, 93215-16, 93220, 93222, 93224-26, 93238,
       Madera–93601-02, 93604, 93614, 93636-39, 93643-45, 93653, and 93669;                  93240-41, 93243, 93250-52, 93263, 93268, 93276, 93280, 93285,
       Mariposa–93623;                                                                       93287, 93301-09, 93311-14, 93380, 93383-90, 93501-02, 93504-05,
       Napa–94503, 94508, 94515, 94558-59, 94562, 94567 (except the                          93518-19, 93531, 93560-61, and 93581.
       community of Knoxville), 94573-74, 94576, 94581, and 94599;
       Sacramento, San Joaquin, and Solano–All ZIP codes;

Anthem = Anthem Blue Cross PPO
KPNC = Kaiser Permanente Northern California
KPSC = Kaiser Permanente Southern California
                                                                                 17
California Major Risk Medical Insurance Program
Monthly Subscriber Contributions
Area 3
Counties: Alameda, Contra Costa, Marin, San Francisco, San Mateo, Santa Clara.
    Below are available health plans listed by service area and ZIP codes. Some health plans may not be available in your area.
Rating Group                                               Age                    Anthem                            CC4                     KPNC5
Subscriber Only                                            <15                    $323.10                        $219.92                    $242.30
                                                          15-29                   $476.90                        $279.69                    $305.38
                                                          30-34                   $595.10                        $406.37                    $360.84
                                                          35-39                   $647.50                        $406.37                    $387.48
                                                          40-44                   $727.90                        $468.08                    $434.79
                                                          45-49                   $765.50                        $468.08                    $477.70
                                                          50-54                   $914.60                        $624.98                    $551.63
                                                          55-59                  $1,063.10                       $624.98                    $631.49
                                                          60-64                  $1,233.70                       $789.59                    $699.51
                                                          65-69                  $1,381.80                      $1,059.64                  $1,066.88
                                                          70-74                  $1,455.80                      $1,059.64                  $1,126.29
                                                           >74                   $1,542.10                      $1,059.64                  $1,194.93
Subscriber &                                               <15                    $520.30                        $542.68                    $483.48
1 Dependent                                               15-29                   $892.00                        $542.68                    $644.80
                                                          30-34                   $999.20                        $720.14                    $733.53
                                                          35-39                  $1,065.00                       $720.14                    $808.95
                                                          40-44                  $1,164.20                       $889.88                    $887.33
                                                          45-49                  $1,263.30                       $889.88                    $930.23
                                                          50-54                  $1,494.20                      $1,219.12                  $1,109.18
                                                          55-59                  $1,783.70                      $1,219.12                  $1,228.98
                                                          60-64                  $2,053.50                      $1,574.05                  $1,399.04
                                                          65-69                  $2,299.90                      $2,065.28                  $1,892.08
                                                          70-74                  $2,423.10                      $2,065.28                  $1,996.33
                                                           >74                   $2,566.80                      $2,065.28                  $2,111.29
Subscriber &                                               <15                    $716.40                       $1,000.50                   $825.63
2 or More Dependents                                      15-29                  $1,302.00                      $1,000.50                  $1,055.93
                                                          30-34                  $1,429.80                      $1,105.93                  $1,277.76
                                                          35-39                  $1,542.30                      $1,105.93                  $1,277.76
                                                          40-44                  $1,655.30                      $1,316.85                  $1,296.99
                                                          45-49                  $1,809.00                      $1,316.85                  $1,296.99
                                                          50-54                  $2,041.40                      $1,507.16                  $1,434.53
                                                          55-59                  $2,326.80                      $1,507.16                  $1,434.53
                                                          60-64                  $2,645.00                      $1,828.67                  $1,620.88
                                                          65-69                  $2,962.40                      $2,448.50                  $2,458.61
                                                          70-74                  $3,121.10                      $2,448.50                  $2,599.10
                                                           >74                   $3,306.30                      $2,448.50                  $2,749.68
4   Contra Costa Health Plan available only in Contra Costa County.
5   Kaiser Permanente Northern California available only to residents in these ZIP codes in these counties:
       Alameda–All ZIP codes;
       Contra Costa–All ZIP codes;
       Marin–All ZIP codes;
       San Francisco–All ZIP codes;
       San Mateo–All ZIP codes;
       Santa Clara–94022-24, 94035, 94039-43, 94085-89, 94301-06, 94309, 95002, 95008-09, 95011, 95013-15, 95020-21, 95026, 95030-33, 95035-38,
       95042, 95044, 95046, 95050-56, 95070-71, 95101, 95103, 95106, 95108-13, 95115-36, 95138-41, 95148, 95150-61, 95164, 95170, 95172-73, 95190-
       94, and 95196.



Anthem = Anthem Blue Cross PPO
CC = Contra Costa Health Plan
KPNC = Kaiser Permanente Northern California
                                                                           18
California Major Risk Medical Insurance Program
Monthly Subscriber Contributions
Area 4
Counties: Orange, Santa Barbara, Ventura.
    Below are available health plans listed by service area and ZIP codes. Some health plans may not be available in your area.
Rating Group                                                   Age                              Anthem                                 KPSC6
Subscriber Only                                                <15                              $291.80                             $216.24
                                                              15-29                             $431.00                             $277.06
                                                              30-34                             $537.70                             $327.26
                                                              35-39                             $585.10                             $351.98
                                                              40-44                             $657.50                             $395.60
                                                              45-49                             $691.80                             $433.44
                                                              50-54                             $826.50                             $500.34
                                                              55-59                             $960.50                             $573.06
                                                              60-64                            $1,115.00                            $635.60
                                                              65-69                            $1,248.80                            $993.73
                                                              70-74                            $1,315.70                           $1,047.33
                                                               >74                             $1,393.70                           $1,109.55
Subscriber &                                                   <15                              $498.50                             $431.34
1 Dependent                                                   15-29                             $866.30                             $584.69
                                                              30-34                            $1,001.50                            $664.70
                                                              35-39                            $1,062.80                            $734.51
                                                              40-44                            $1,157.70                            $805.78
                                                              45-49                            $1,271.20                            $843.58
                                                              50-54                            $1,525.60                           $1,006.50
                                                              55-59                            $1,806.40                           $1,115.58
                                                              60-64                            $1,926.60                           $1,269.75
                                                              65-69                            $2,157.70                           $1,768.05
                                                              70-74                            $2,273.30                           $1,865.18
                                                               >74                             $2,408.20                           $1,982.30
Subscriber &                                                   <15                              $751.60                             $738.15
2 or More Dependents                                          15-29                            $1,214.70                           $1,038.50
                                                              30-34                            $1,381.00                           $1,159.20
                                                              35-39                            $1,454.40                           $1,159.20
                                                              40-44                            $1,495.70                           $1,178.11
                                                              45-49                            $1,652.80                           $1,178.11
                                                              50-54                            $1,871.60                           $1,301.75
                                                              55-59                            $2,103.00                           $1,301.75
                                                              60-64                            $2,390.20                           $1,471.93
                                                              65-69                            $2,677.00                           $2,239.21
                                                              70-74                            $2,820.50                           $2,362.96
                                                               >74                             $2,987.80                           $2,511.08
6   Kaiser Permanente Southern California available only to residents in these ZIP codes in these counties:
       Orange–All ZIP codes;
       Ventura–91319-20, 91358-62, 91377, 93001-07, 93009-93012, 93015-16, 93020-22, 93030-36, 93040-44, 93060-66, 93094, and 93099.




Anthem = Anthem Blue Cross PPO
KPSC = Kaiser Permanente Southern California
                                                                          19
California Major Risk Medical Insurance Program
Monthly Subscriber Contributions
Area 5
County: Los Angeles.
    Below are available health plans listed by service area and ZIP codes. Some health plans may not be available in your area.
Rating Group                                                          Age                                  Anthem                          KPSC 7
Subscriber Only                                                      <15                                  $310.80                          $216.24
                                                                    15-29                                 $458.90                          $277.06
                                                                    30-34                                 $572.70                          $327.26
                                                                    35-39                                 $622.70                          $351.98
                                                                    40-44                                 $700.40                          $395.60
                                                                    45-49                                 $736.50                          $433.44
                                                                    50-54                                 $880.10                          $500.34
                                                                    55-59                                $1,023.00                         $573.06
                                                                    60-64                                $1,187.00                         $635.60
                                                                    65-69                                $1,329.40                         $993.73
                                                                    70-74                                $1,400.60                        $1,047.33
                                                                     >74                                 $1,483.70                        $1,109.55
Subscriber &                                                         <15                                  $501.80                          $431.34
1 Dependent                                                         15-29                                 $921.20                          $584.69
                                                                    30-34                                $1,033.00                         $664.70
                                                                    35-39                                $1,113.50                         $734.51
                                                                    40-44                                $1,173.70                         $805.78
                                                                    45-49                                $1,297.40                         $843.58
                                                                    50-54                                $1,517.40                        $1,006.50
                                                                    55-59                                $1,801.10                        $1,115.58
                                                                    60-64                                $1,992.40                        $1,269.75
                                                                    65-69                                $2,231.50                        $1,768.05
                                                                    70-74                                $2,351.00                        $1,865.18
                                                                     >74                                 $2,490.50                        $1,982.30
Subscriber &                                                          <15                                 $782.30                          $738.15
2 or More Dependents                                                 15-29                               $1,282.00                        $1,038.50
                                                                     30-34                               $1,413.10                        $1,159.20
                                                                     35-39                               $1,512.80                        $1,159.20
                                                                     40-44                               $1,592.70                        $1,178.11
                                                                     45-49                               $1,759.70                        $1,178.11
                                                                     50-54                               $1,992.70                        $1,301.75
                                                                     55-59                               $2,239.20                        $1,301.75
                                                                     60-64                               $2,545.10                        $1,471.93
                                                                     65-69                               $2,850.50                        $2,239.21
                                                                     70-74                               $3,003.20                        $2,362.96
                                                                      >74                                $3,181.40                        $2,511.08
7   Kaiser Permanente Southern California available to residents in all ZIP codes in Los Angeles County except 90704 (Catalina Island).




Anthem = Anthem Blue Cross PPO
KPSC = Kaiser Permanente Southern California
                                                                                  20
California Major Risk Medical Insurance Program
Monthly Subscriber Contributions
Area 6
Counties: Riverside, San Bernardino, San Diego.
    Below are available health plans listed by service area and ZIP codes. Some health plans may not be available in your area.
Rating Group                                                       Age                                Anthem                                 KPSC8
Subscriber Only                                                    <15                                $295.40                               $216.24
                                                                  15-29                               $436.20                               $277.06
                                                                  30-34                               $544.20                               $327.26
                                                                  35-39                               $592.20                               $351.98
                                                                  40-44                               $665.50                               $395.60
                                                                  45-49                               $700.20                               $433.44
                                                                  50-54                               $836.50                               $500.34
                                                                  55-59                               $972.10                               $573.06
                                                                  60-64                              $1,128.30                              $635.60
                                                                  65-69                              $1,263.70                              $993.73
                                                                  70-74                              $1,331.40                             $1,047.33
                                                                   >74                               $1,410.40                             $1,109.55
Subscriber &                                                       <15                                $477.00                               $431.34
1 Dependent                                                       15-29                               $847.00                               $584.69
                                                                  30-34                               $947.90                               $664.70
                                                                  35-39                              $1,023.30                              $734.51
                                                                  40-44                              $1,108.30                              $805.78
                                                                  45-49                              $1,188.00                              $843.58
                                                                  50-54                              $1,400.40                             $1,006.50
                                                                  55-59                              $1,632.30                             $1,115.58
                                                                  60-64                              $1,868.10                             $1,269.75
                                                                  65-69                              $2,092.30                             $1,768.05
                                                                  70-74                              $2,204.40                             $1,865.18
                                                                   >74                               $2,335.20                             $1,982.30
Subscriber &                                                       <15                                $688.10                               $738.15
2 or More Dependents                                              15-29                              $1,208.20                             $1,038.50
                                                                  30-34                              $1,324.40                             $1,159.20
                                                                  35-39                              $1,405.60                             $1,159.20
                                                                  40-44                              $1,513.60                             $1,178.11
                                                                  45-49                              $1,670.00                             $1,178.11
                                                                  50-54                              $1,844.40                             $1,301.75
                                                                  55-59                              $2,107.40                             $1,301.75
                                                                  60-64                              $2,410.70                             $1,471.93
                                                                  65-69                              $2,700.00                             $2,239.21
                                                                  70-74                              $2,844.60                             $2,362.96
                                                                   >74                               $3,013.40                             $2,511.08
8   Kaiser Permanente Southern California available only to residents in these ZIP codes in these counties:
       Riverside–91752, 92220, 92223, 92320, 92501-09, 92513-19, 92521-22, 92530-32, 92543-46, 92548, 92551-57, 92562-64, 92567, 92570-72, 92581-87,
       92589-93, 92595-96, 92599, 92860, and 92877-83;
       San Bernardino–91701, 91708-10, 91729-30, 91737, 91739, 91743, 91758, 91761-64, 91784-86, 92252, 92256, 92268, 92277-78, 92284-86, 92305, 92307-08,
       92313-18, 92321-22, 92324-26, 92329, 92331, 92333-37, 92339-41, 92344-46, 92350, 92352, 92354, 92357-59, 92369, 92371-78, 92382, 92385-86, 92391-95,
       92397, 92399, 92401-08, 92410-15, 92418, 92423-24, and 92427;
       San Diego–91901-03, 91908-17, 91921, 91931-33, 91935, 91941-47, 91950-51, 91962-63, 91976-80, 91987, 92007-92011, 92013-14, 92018-27,
       92029-30, 92033, 92037-40, 92046, 92049, 92051-52, 92054-58, 92064-65, 92067-69, 92071-72, 92074-75, 92078-79, 92081-85, 92090-93, 92096,
       92101-24, 92126-32, 92134-40, 92142-43, 92145, 92147, 92149-50, 92152-55, 92158-79, 92182, 92184, 92186-87, and 92190-99.




Anthem = Anthem Blue Cross PPO
KPSC = Kaiser Permanente Southern California
                                                                              21
MRMIP Enrollment Application Checklist

Please use the following checklist to ensure that your application is complete:
 o Review the handbook to learn about the eligibility requirements for the California Major Risk Medical
   Insurance Program (MRMIP) and choose your health plan before completing the Enrollment Application.
 o Complete the Enrollment Application on pages 23-26 of this handbook. All questions must be fully answered.
   If you do not provide all necessary information (including the required documentation, signatures, and
   payments), your application will be incomplete, which will delay the processing of your application.
 o Sign and date the completed Enrollment Application on page 26.
 o Attach the following items (your entire application may be returned to you if you do not provide
   the following):
     o Your supporting documentation that indicates your eligibility for the MRMIP.
       (Page 2 of this handbook describes how eligibility can be demonstrated.)
          • Copy of denial for individual insurance within the previous 12 months; or
          • Copy of letter indicating involuntary termination of health insurance within the previous 12 months
            for reasons other than nonpayment of premium or fraud; or
          • Copy of letter indicating individual health insurance premium in excess of the MRMIP subscriber
            contribution amount.
          • If you are eligible for Medicare Part A and Part B, copy of a Medicare letter explaining that you are
            eligible solely because of end-stage renal disease.
          • If you are applying for deferred enrollment, copy of letter indicating when coverage ends.
     o A check for one month’s contribution for subscriber and/or dependent for your chosen health plan.
       Make check payable to California Major Risk Medical Insurance Program.
       (Monthly subscriber and/or dependent contribution amounts are listed on pages 16-21 of this
       handbook). Payments that do not equal the exact amount that is due will delay the processing of
       your application.
     o Proof of Qualifying Prior Coverage (if applicable) to waive all or part of your Exclusion/Waiting Period
       must be received prior to or with your first month’s contribution for credit to be given. (Please see pages
       4-5 of this handbook for more information.)
     o Insurance Agents or Brokers: You must complete all boxes at the bottom of page 23 of the Enrollment
       Application to request reimbursement.
     o Mail the completed Enrollment Application with your check and all necessary attachments to:
                                              California Major Risk
                                            Medical Insurance Program
                                                 P.O. Box 9044
                                             Oxnard, CA 93031-9044

                                                          22
MRMIP Enrollment Unit
1-800-289-6574
Mon. – Fri. from 8:30 a.m. to 7:00 p.m.


        California Major Risk Medical Insurance Program
        Enrollment Application
        Instructions:
        Thank you for applying for the California Major Risk Medical Insurance Program. Please follow these instructions
        to allow us to better process your application.
        • Read the handbook to learn about eligibility and choose your health plan before completing this application.
        • You (the applicant/parent/legal guardian) must complete this application. You are solely responsible for its
          accuracy and completeness.
        • All questions must be fully answered. If you do not provide all necessary information (including the
          required supporting documentation, signatures, and payments), your application will be incomplete,
          which will delay the processing of your application or may result in a denial.
        • Even if this application is approved, any misstatements or omissions may result in future claims being denied
          and the policy being rescinded.




                                     Attach check to page 24 where indicated.
                  Please submit one month’s subscriber contribution for your chosen health plan
                                              (refer to pages 16-21).
                        Regardless of which plan you choose, make your check payable to
                              California Major Risk Medical Insurance Program.

                           Submit check, application and all necessary documentation to:
                                                        California Major Risk
                                                       Medical Insurance Program
                                                            P.O. Box 9044
                                                       Oxnard, CA 93031-9044


 INSURANCE AGENT and BROKER: If you assisted your client in completing this application, please complete this
 section. You must complete all boxes. You will not be paid if you do not complete this section prior to submission.
 Missing information cannot be submitted at a later date for payment. (Please see note to Agents on pages 2-3 of the
 handbook.) Use blue or black ink only.
 Agent Name                                                                 CA Agent/Broker License No.                     Tax I.D. No:/Soc. Sec. No.


 Street Address                                                             I understand that no Agent payment will be made unless and until this
                                                                            applicant is enrolled in the Program.

 City                                 State            ZIP Code


 Phone No.                                    FAX No: (if available)
                                                                            Signature
                                                                                                                                                         12/09


                                                                       23
 1. Check One:                                    New Enrollment                              Add Dependents                                            Use blue or black ink only.
                                                               (Remember: Regardless of your choice of health plan, make check payable to
 2. Choice of Health Plan:                                     California Major Risk Medical Insurance Program.)

 Health Plan Name                                                                             (For internal use only)


                                                                                                                                                   (If parent or legal guardian is completing this application for
 3. Applicant Information: Applicant must complete this section.                                                                                   the applicant, please mark this box.     )

 Last Name                                                     First Name                                  M.I.         Social Security Number (optional)          Age        Birthdate                            10      Male
                                                                                                                                                                               Mo       Day           Yr
                                                                                                                                                                                                                   20      Female

 Check One 1          Single      2    Married     3         Widowed         Family Size (Optional)                Annual Household Income                    Home Phone                                  County
             4    Divorced        5    Registered Domestic Partner
                                                                                                                   (Optional)
                                                                                                                                                              (          )
 Street Address (must be completed; P.O. Box not acceptable)                                       Suite or Unit #                         City                              State                        ZIP Code


 Billing Name, if different


 Billing Address, if different                                                                                                             City                              State                        ZIP Code


 Employer, if employed                                                                                                                     Occupation                        Business Phone
                                                                                                                                                                             (           )
 Employer Street Address                                                                                                                   City                              State                        ZIP Code




 4. Race/Ethnicity (Optional): Check box which best applies.
                                                                Hispanic                                                 Asian                                                   Pacific Islander
     10      Aleut                                              21        Cuban                                          41      Asian Indian                                    61    Filipino
     11      American Indian, Native American                   22        Mexican, Mexican-American,                     42      Cambodian                                       62    Guamanian
                                                                          Chicano
     12      Black/African American                                                                                      43      Chinese                                         63    Samoan
                                                                23        Puerto Rican
     13      Eskimo                                                                                                      44      Japanese
                                                                92        Other; please specify:                                                                                 Other not listed; please specify:
     14      White                                                                                                       45      Korean                                          99
                                                                                                                         46      Laotian
                                                                                                                         47      Vietnamese
                                                                                                                         94      Other; please specify:
                 STAPLE CHECK HERE
            payable to California Major Risk
              Medical Insurance Program

 5. Family Information: List all additional family members to be enrolled.
30        Husband              Last Name                                                 First Name                                               MI    Social Security Number (optional)           Age     Birthdate
40        Wife
30        Registered                                                                                                                                                                                        Mo       Day   Year
          Domestic
          Partner (RDP)

50        Son                                                                                                Status
70        Daughter                                                                                               S         M        RDP

51        Son                                                                                                Status
71        Daughter                                                                                               S         M        RDP

52        Son                                                                                                Status
72        Daughter                                                                                               S         M        RDP

53        Son                                                                                                Status
73        Daughter                                                                                               S         M        RDP

54        Son                                                                                                Status
74        Daughter                                                                                               S         M        RDP

If a dependent child is over 23 years of age, send doctor’s record showing that the dependent child cannot work for a living because of a physical or mental disability which existed before
becoming 23 years old with the application.
Is this dependent child covered by Medicare?           Yes           No                                                                                                                                                    12/09




                                                                                                                  24
6. Program Eligibility: To be eligible for the Program you must answer “yes” to one of the first four questions. Provide a copy of
    a letter or formal written communication documenting all “yes” answers. (See page 2.)                                                    Applicant   Dependent
                                                                                                                                             Yes   No      Yes   No

1. Within the past 12 months, have you been denied individual health insurance?

2. Within the past 12 months, have you been involuntarily terminated from health insurance coverage for reasons other than fraud
   or nonpayment of premium?

3. Within the past 12 months, have you been offered an individual premium higher than the rate for the first choice health plan
   listed on this application?

4. Are you currently ineligible, but anticipate becoming eligible, and want to apply for a deferred enrollment?
   (See page 2.)

5. Have you and your dependent(s), if any, met the requirements to waive all or part of the exclusion/waiting period? (See pages 4-5)
   under “How You May Waive All or Part of the Exclusion/Waiting Period.’’) Please provide a copy of supporting documantation.
                                  Name of prior insurance company:
                                  Effective date of prior coverage:
                                  Termination date of prior insurance:

6. Within the past 12 months, were you covered in a similar high-risk pool sponsored by another state before becoming a California
   resident?


7. Declarations: Please read each of the following statements carefully and initial each statement. Any untrue or inaccurate
    responses may be reason for loss of enrollment or application of other sanctions.                                                        Applicant   Dependent
                                                                                                                                              Initials    Initials

1. I declare that no individual listed on this application is eligible for both Part A (hospital) and Part B (professional) of
   Medicare. If you are eligible solely because of end-stage renal disease, leave blank and provide Medicare eligibility letter as
   proof of end-stage renal disease. (Medicare is a federal program that provides health services to older Americans and disabled
   persons.)

2. I declare that all individuals listed on this application are residents of the state of California. (See page 2 under “Eligibility” for
   the definition of California resident.)

3. I declare that I am not currently eligible to purchase any health insurance for continuation of benefits from my employer
   under the provisions of 29 U.S. Code 1161 et seq. (COBRA), or under the provisions of Insurance Code Sections 10128.50
   et seq. and Health and Safety Code Sections 1366.20 et seq. (Cal-COBRA). These are the laws which allow people to buy
   into their employer’s health insurance for at least 36 months after they leave their employer. (If you are currently on COBRA,
   leave blank and refer to page 2.)

4. I declare that all individuals listed on this application will abide by the rules of participation, the utilization review process and
   the dispute resolution process of the participating health plan in which the individual is enrolled. A dispute resolution process
   may include binding arbitration rather than a court trial to resolve any claim, including a claim for malpractice, asserted by
   me, my enrolled dependents, heirs, personal representatives, or someone with a relationship to us, against the participating
   health plan, or against the employees, partners, or agents, of the participating health plan.

5. I declare that I have reviewed the benefits offered by the MRMIP and the subscriber contribution amounts.

6. I declare that no individual listed on this application was excluded from group health coverage solely for the purpose of being
   made eligible for the MRMIP.

7. I declare that I understand and will follow the rules and regulations of the MRMIP. I understand that depositing a subscriber
   contribution check shall not constitute acceptance on the part of the MRMIP, or any of its subcontractors, if the application
   is not approved or if the member has already been disenrolled for nonpayment of subscriber contribution, fails to meet
   program eligibility requirements, commits program fraud, or because the dependent ceases to be a dependent, upon request by
   the member, or for any other reason.

8. I declare that I have not been terminated within the last 12 months from a Post-MRMIP Graduate health plan, which became
   available through guaranteed coverage after my eligibility for MRMIP ended (Health and Safety Code Section 1373.62 or
   Insurance Code Section 10127.15) due to nonpayment of premiums, as a result of my request to voluntarily disenroll, or as a
   result of fraud.
                                                                                                                                                                     12/09

                                                                                     25
     8. Authorization and Conditions of Enrollment
          Required by the Confidentiality of Medical Information Act of 1/1/80, Sect 56 et seq. of the California Civil Code for all applicants
          of 18 years and over. I authorize any insurance company, physician, hospital, clinic or health care provider to give Major Risk Medical
          Insurance Program Administrator any and all records pertaining to any medical history, services or treatment provided to anyone listed
          on this application for purpose of review, investigation or evaluation. This authorization becomes immediately effective and shall remain
          in effect as long as Administrator requires. A photocopy of this Authorization is as valid as the original.
          Privacy Notification
          The Information Practices Act of 1977 and the Federal Privacy Act require this Program to provide the following to individuals who
          are asked by the Major Risk Medical Insurance Program (established by Part 6.5 of Division 2 of the Insurance Code) to supply
          information: The principal purpose for requesting personal and medical information is for subscriber identification and program
          administration. Program regulations (Chapter 5.5 of Title 10 of the California Code of Regulations, Sections 2698.100 et seq.) require
          every individual to furnish appropriate information for application to the Major Risk Medical Insurance Program. Failure to furnish this
          information may result in the return of the application as incomplete. The following information on the application is voluntary: social
          security number, race/ethnicity information and health history.
          Personal information provided on this form will not be furnished to any other governmental agency.
          An individual has a right of access to records containing his/her personal information that are maintained by the Major Risk Medical
          Insurance Program. The official responsible for maintaining the information is: Deputy Director, Eligibility, Enrollment and Marketing,
          Managed Risk Medical Insurance Board, P.O. Box 2769, Sacramento, CA 95812-2769. The Board may charge a small fee to cover the
          cost of duplicating this information.
          I understand that this is a state program and my rights and obligations under it will be determined under Part 6.5 Division 2 of
          the California Insurance Code and at the regulation of Title 10, Chapter 5.5
          I understand that if this application is approved, the effective date of coverage will be determined according to applicable laws
          and regulations and I will be informed in writing of the effective date. (Do not cancel any current coverage until you hear from
          MRMIP.)
          I understand that there may be waiting periods for pre-existing conditions.
          Each plan has its own rules for resolving disputes about the delivery of services and other matters. Some plans say you must
          use binding arbitration for disputes; others do not. Some plans say that claims for malpractice must be decided by binding
          arbitration; others do not. If the plan you choose requires binding arbitration, you are giving up your right to a jury trial
          and cannot have the dispute decided in court. To find out more about how a plan resolves disputes, you can call the plan and
          request an Evidence of Coverage or Certificate of Insurance booklet.
          This plan DOES NOT require binding arbitration: Contra Costa Health Plan.
          These plans DO require binding arbitration of disputes INCLUDING malpractice, so long as the disputes are beyond the
          jurisdictional limit of the small claims court: Anthem Blue Cross and Kaiser Permanente.
          I, the applicant, declare that I have read and understand the information on this form and agree to the Authorizations and
          Conditions of Enrollment. I certify that the information provided on this application is true and correct.


 X                                                                                X
Signature of Applicant/Parent or Legal Guardian Required     Date               Signature of Applicant’s Spouse/Registered Domestic Partner Required   Date
                                                                                (If listed on this application)




 X                                                                                X
Signature of Applicant’s Dependent Age 18 or over Required   Date               Signature of Applicant’s Dependent Age 18 or over Required             Date
(If listed on this application)                                                 (If listed on this application)



       After filling out the application, signing and securing all necessary documentation, submit
                    a check for one month’s contribution for your chosen health plan.
         Make your check payable to California Major Risk Medical Insurance Program.
                                    Mail your completed application to:
                                            California Major Risk
                                        Medical Insurance Program
                                               P.O. Box 9044
                                          Oxnard, CA 93031-9044
                                                                                                                                                              12/09


                                                                           26
                      Flex
                      Your

                      Power
      California’s Energy Challenge
California is facing an energy challenge. To reduce the risk of power
outages, everyone can help by reducing the demand for electricity by
using less energy.
California has the power of the world’s sixth largest economy. Your
efforts, times 35 million Californians, will make a real difference.

                       All you have to do is
                      FLEX YOUR POWER

Simple things you can do right now to cut your energy costs are:

  • Keep energy use low during peak demand hours from 5 a.m. to
    9 a.m. and 4 p.m. to 7 p.m.
  • Turn off unneeded lights and appliances. Unplug that spare
    refrigerator out in the garage if you don’t really need it.
  • Avoid using dishwashers, clothes washers, dryers and ovens during
    the peak demand periods. Wash full loads of clothes/or dishes. Use
    the cold setting on your washer if you can.
  • In cool weather, turn your thermostats down to 68º degrees or
    below. Set it at 55º degrees before going to sleep or when away for
    the day. For every 1 degree reduction, you will save up to 5% on
    your heating costs. Close your shades and blinds at night to keep
    heat from being lost through windows.
  • In warm weather, set your air conditioner to 78º degrees or higher.
    When away from home set the thermostat to 85º degrees. These tips
    can save you up to 20% on your air conditioner costs.
  • Buy Energy Star appliances, products and lights.
  • For more on saving energy and money, go to www.my.ca.gov on
    the Web and click the California’s Energy Challenge site next to the
    FLEX YOUR POWER logo.
1009 CA0014932 12/09

								
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